time for ASV?

[lionel197]

I'm 3 1/2 weeks in to apap. Thanks for all the help and support so far. obstructives are very low but centrals are high. I tried epr off and that increased the number of centrals. Do I need to go to ASV?
http://imgur.com/a/S55qh

[Crimson Nape]

Is this chart representative of your other nights?  If so, two things that can trigger CA's is the first I'd target.
1. Turn off the EPR
2. Consider trying a straight pressure.  I'd set it to 8cm initially, we can work on the other apneas later.

Hang in there!

Edit: I forgot to ask, what medications are you taking?

[OpalRose]

I tried epr off and that increased the number of centrals. Do I need to go to ASV?

How long did you try with the EPR off, and how much higher were the centrals?

Do you have a screenshot of the day/days with the EPR off?  

I do agree with Crimson Napes advice, set to cpap mode, or keep at Apap with the minimum and maximum pressure the same.  Try to turn EPR off or at least turn it down to 1, and give it a few days to see if it makes a difference.  

Keep a record of these changes and print out reports that you can take and discuss with your doctor.

It is early yet in your treatment, and you may very well be headed towards an ASV.  You have to fail at Cpap first.

[Sleeprider]

Lionel, you have split the information pertaining to your therapy and results between three different threads. In every thread has been a request for you to turn off EPR so we can compare the results, and to consider setting pressure at a constant (CPAP) pressure to avoid pressure changes. Both of these features of your autoset can increase CA. You have predominately CA events and I do think you will eventually require ASV for treatment, but we wanted to observe your response to the suggestions of no EPR and constant pressure.

During your sleep test were there any central events? What were your sleep study results? Did you have a titration study? If so, what were the results. You should obtain copies of any tests for your personal record to assist as you move forward in your request for ASV. If you use insurance, you have a pretty long road ahead of you still. If we assume your doctor will accept that you have failed CPAP, his next step will be to evaluate BiPAP. You will certainly fail that as well, but insurance wants you to fail CPAP and bilevel before approving ASV. You will then require cardiac evaluation to ensure you are fit to use ASV, and a titration on ASV/ST to determine if it is effective in resolving your CA events. Finally after all that you may get the machine you need. It's a tough process and will take some time. You can start the ball rolling by discussing with your doctor that your results are unsatisfactory with numerous CA events being recorded by the machine. The way you feel (suffocated, tired, panic, etc) is going to mean more to your doctor than trying to tell him about the machine data. Many doctors are very skeptical about machine data.

It would be very helpful if you would stop creating new threads to discuss the same problem. In trying to help you, the previous discussions and information are important to have together.

[quiescence at last]

Looking forward to seeing if we can help. If there were no central apnea seen in your sleep test, you probably have PAP onset CAs.

Think back to your sleep test. Did you have any panicky reaction then?

I have seen your charts for 18 and 21 May. If this were mine, I would change EPR to Off or 1, and set my min at 6 and max at 8. I would use those settings for at least 4 days and post all 4 days.

Some others on the forum have gone thru similar experiences. They have your best interest in mind.

You might as well call and make an appointment now, especially if you have to wait weeks for it.  By then you will have some answers as well as pointed questions for her.

Good luck,

QAL

[lionel197]

First, thanks again for the help and support. without this forum I would have either given up or gone mad by now. I apologize for any confusion by starting multiple threads; I'm new to blogging and posting on forums. 

Here's some background: besides poor sleep; daytime fatigue, headaches, etc, I was waking after about 5 hours with varying degrees of feeling suffocated to outright panic. BTW I had sleep apnea surgery 10-12 years ago and had my uvula removed; upper palate carved and chin advanced. At that time I was referred directly to surgery with no attempt at cpap. I've also had sinus surgery 15 years ago.

My most recent episode of waking with full on panic led me to my GP who referred me to sleep specialist for in-home sleep study-- I will pick up a copy today, but I understand home study has limited data and not number of centrals vs  obstructives, no titration study, etc. Sleep dr office told me AHI 53 and sent me to pick up avap machine which I've been using for 24 days. The drs office can remotely change the settings and they use a service that receives data from the modem and then sends periodic reports to the doctor. I bought an sd card and installed Rescan and sleepyhead 4 days ago.

My base pressure was 5 and I turned off ramp and asked the dr office to increase because I felt I was struggling to get breaths. They turned the min up to 9. that was a very bad night; felt I was fighting the machine and woke with panic. I called the monitoring service who said centrals "went way up" that night. and talked to dr office who lowered min to 6. Several nights ago I had trouble getting to sleep and woke with high anxiety and realized drs office had raised min to 11. monitoring service said centrals went way up. So I haven't tried  a straight cpap single pressure, but when min was raised to 9 and 11, I had terrible nights; high centrals; and waking with high anxiety.

Also, as suggested, I tried EPR off- I really felt I couldn't breath; so I tried EPR at 2 for two nights and centrals went up (see attachment.) So I went back to EPR at 3. It appears to me that a pattern is emerging -- obstructives are low and I have a cluster of centrals in the first 45-60 mins of falling asleep. I then wake 4.5 -5 hours later with varying degrees of anxiety and then have another cluster of centrals as I try to fall back asleep (please see attachment)

Also someone asked about meds (in relation to high # centrals)- no opiates and no Parkinson's to cause centrals. again, centrals appear to occur in clusters as I'm falling asleep.

Well, thanks for listening; I hope this makes some sense; I'll stick to one thread. Cheers.

[Sleeprider]

Lionel, do an internet search on "complex apnea". You have obstructive sleep apnea that is found by the sleep tests; however 5-15% of individuals will develop central apnea when subjected to CPAP pressure. For these people ASV is the eventual solution. Your doctor needs to be made aware of your suspicion of complex sleep apnea, in order to do the proper testing, and take a different approach to therapy. If your doctor is not familiar with complex apnea and is not conversant in the topic, then you need a different doctor.

This blog post by Robert Thomas is particularly good. Search "Complex Apnea" at MyApnea website.

[TASmart]

L:

From the data you have presented you have not done an EPR off situation. As Sleeprider has suggested you need to try a night with the EPR off, the Ramp off, and a moderate pressure in a CPAP mode. This is the only way that I get good results, I start getting both CA events and Hypopneas if I use the EPR at all. Whine you said you could not breath with the EPR off, what was the pressure your were using, and was the issue on inhale or exhale?

If you have not yet done so, you need to request and download the clinicians manual so you know how to change your own settings. Click on the link for set-up manuals at the top of the page, locate your model and follow the directions. There is little need to have to call the Dr when you need to adjust the settings, especially in this set up phase. Keep posting your results, and let's see if we can help you, or if not help you to justify and rationalize an ASV to your Dr.

Good Sleep to ya!

[lionel197]

Thanks. I have read the manual on how to enter "clinical mode" and change EPR, etc. but I'm a little reluctant since the dr office and equipment provider never even told me about this mode. Can I get in trouble or lose insurance benefit if I'm making changes not approved by the dr?

Also, I really don't think I could tolerate an entire night of EPR off and constant pressure. I turned EPR off, ramp off, and started at my min pressure of 6. With these settings, I felt like even the slightest initial inspiratory effort would trigger a bellows inflating my lungs and I felt I hade to forcefully exhale every breath. I started getting light headed. I think I began hyperventilating.

If get up the courage to try, When you say a "moderate" cpap pressure, what would you suggest I try?

PS: I picked up  my initial sleep study result today -- zero centrals! So I think sleeprider is spot on.

[TASmart]

Most sleep clinics and doctors rely on the DME to teach the patient how to use the equipment. The Dr does prescribe a pressure and/or bilevel setting for therapy. For that you need to look at your sleep prescription. Mine says I may use EPR is desired for comfort. IT is not comfortable for me, and my results are worse if I do use it. Crimson Nape suggested a fixed pressure above, I'd try that. What did you titration study call for? And what kind of therapy?


EPR has no effect in the inspiration phase of your therapy, so if you feel like your lungs are being inflated that's your fear of the process. The pressure boost at 8 cm is the pressure it takes to suck water up a straw 8 cm or about 3.1 inches. On the expiring side, at 8 cm you are having to overcome the pressure of blowing bubbles in a glass of water with a straw inserted 3.1 inches

As far as getting in trouble, I have not nor have all the member here who have taken control of their therapy due to incomplete or poor advise.

I think an awful lot of those flagged CA are what is called sleep/wake junk as you transition between sleep and wake - they are not really clear airway things at all. They may be clear airway but until you make the effort to really optimize your therapy you will not know.

I also think you are having really severe anxiety issues with your treatment - and I know its daunting, but lots of us have gotten through the iniial stages and its a beautiful thing when you do! There is some inflation feel when you breath in, and some resistance when you exhale. For me, the feeling of resistance on exhalation only takes a few breaths every night. I actually kind of like the feeling of inspirations, makes breathing even ore easy than the natural effort it is.

Good Sleep!