Victim of centrals only?

[bonum.noctem]

It's been a while. I passed by here in July after a home screening revealed that I have "mild" OSAS. At that point I had to wait three more month for the full diagnoses in the sleep clinic, which just took place a few days ago. Since I didn't want to wait that long, @Pugsy organized a barely used AirCurve 10 VAuto + AirFit P10 for me, that I have played around with a few times, but didn't really succeed because it didn't seem to lead to any proper results, which made me change my mind to wait for the sleep clinic appointment first.

Now with the combined diagnoses + therapy night in the sleep clinic behind me, I'm not really any further. They put me to sleep with all the cables & sensors attached, woke me up at 2 a.m. to put on the mask (attached to a ResMed S9 CPAP, not sure which exact model), and woke me up at 6 a.m. to tell me that CPAP does not seem to be working for me, and that I will have to try again with a BiLevel machine in a separate therapy night. They did not give me any report from that night, only told me that when laying on my back I reach an AHI of around 60 while being borderline when laying to either side. The problem is now that the appointment for the second therapy night is scheduled for end of March 2019, but they put me on their jumper list in case someone cancels his/her appointment.

So I hooked up my AirCurve 10 VAuto + AirFit P10 again yesterday, made a reset to default settings (because I wasn't comfortable with the previously determined setup) and this is what came from it:

screenshot-20181030-170547.png (222.69 KiB) Viewed 11478 times

At first I could not fall asleep, tried to stay on my back, then swapped between both sides and also tried sleeping on my belly during the rest of the night. I took a toilet break after midnight, and could not really sleep all night long changing sleep position all the time.

In the morning breathing somehow changed, it didn't feel that much assisted anymore and I woke up with the feeling that I must have swallowed quite some air.

I know that the default setting with Min EPAP, Max EPAP and PS is not the recommended approach, but I wanted to give it a try to see what the outcome may be, because other settings I have tried before (Min EPAP 6 and PS 4) did not make it any better.

Looking at the results in SleepyHead I don't really know what to think.

How can it be pretty much centrals only?
Is this an indication that I may need an ASV machine?
Which settings should I try next?

[Pugsy]

Short on time so have to be quick.
Been wondering what was going on with you.

Yes, you may need ASV but let's try one setting change to see if you get lucky.

Turn PS off...
Set PS minim to 0 and PS maximum to 0 and see what happens.

[bonum.noctem]

Short on time so have to be quick. Been wondering what was going on with you.

Yes, I'm sorry, I wanted to give feedback, but I received your parcel right before a business trip, took the machine with me, didn't succeed, got sidetracked by work and other stuff, so I thought I'd just wait for the findings in the sleep clinic after all.

Yes, you may need ASV but let's try one setting change to see if you get lucky. Turn PS off... Set PS minim to 0 and PS maximum to 0 and see what happens.

OK, that didn't come to mind, I'll give it a try this night and report back tomorrow.

[palerider]

Start by doing what Pugsy said. Turn off PS, see what happens.

If it feels like you're not getting enough air, increase the minEPAP by two or three.

[bonum.noctem]

Well, it took a few nights for that second test with PS off due to a slight nasal infection, but here it is from last night:

screenshot-20181103-173709.png (202.47 KiB) Viewed 11398 times

I did not really get much sleep, with PS off breathing felt quite unnatural, and I had to increase Min EPAP from 4 to 8 in two steps. Trying to fall asleep on my back didn't work out, and it then was a rolling from one side to the other the rest of the night. I must have swallowed quite some air again (although I'm pretty good at keeping my tongue at the roof of the mouth).

The result with pretty much only CAs is weird. The home screening earlier this year showed an AHI of 6.7 with obstructive 5.3 and hypopnea 1.4 but no centrals at all.

I usually can fall asleep when laying on either side or on my belly quite well, but I don't sleep well and change position often during the night. According to a snore app on my mobile and my wife I'm a pretty bad snorer, which indicates obstructive airway syndrome, but it is extremely rare that I wake up gasping for air.

So where are the centrals coming from? The machine? (A)PAP & (A)Bi-PAP really not working for me?

Any other settings I should try with my AirCurve 10 VAuto or give up and report back to the sleep clinic with my findings that I may need to try ASV during my next therapy night?

I'm quite discouraged right now. I had high hopes for that therapy after digging in deep earlier this year while having to wait that long for the sleep clinic diagnoses, and now I'm not any further at all.

[Pugsy]

Watch this video. It sort of does a decent job explaining where the centrals are coming from with the addition of cpap pressure.
https://www.youtube.com/watch?v=CU-XTcf ... e=youtu.be

There is a remote chance that with time the breathing will stabilize and the centrals will fade away. How much time we never know but usually months from what I have read....and even then it's a maybe.

ASV is likely the next step but you might also talk to the doctor about your pre cpap AHI and any chance that it might be controlled with positional sleep restrictions.
With a diagnostic AHI of less than 7...that's mild and I would be looking at thing real closely as to just how badly you even need any sort of cpap therapy.

Turning PS off was a last ditch try at something to see if it was maybe the PS that was the trigger for the unstable breathing that causes the centrals. It works for a very small minority of people who have centrals pop up with cpap therapy...you didn't get lucky and have it work for you.

It's actually a carbon dioxide imbalance that cause the centrals to pop up....
what happens with cpap therapy is the body breathes in such a manner that the carbon dioxide gets washed out of the body too soon.
Carbon dioxide doesn't get a chance to build up in the blood stream normally.
It's actually the carbon dioxide levels that need to be up at a certain level to cause the brain to send the breathe signal.
When the carbon dioxide levels don't get high enough the brain doesn't send the signal to breathe and the centrals happen because we aren't breathing.
What happened to you...happens to about 10 to 15% of the people who don't have a central problem when not on cpap but end up with a problem with the addition of CPAP.
When that does happen...the usual first line of trying to fix it is the bilevel machine like you have...sometimes that works just fine and nothing else is needed. When regular bilevel doesn't fix the problem then the next step is ASV or similar machine that has a back up rate available to force you to breathe when the brain doesn't send the signals to breathe.

[palerider]

Well, it took a few nights for that second test with PS off due to a slight nasal infection, but here it is from last night:

screenshot-20181103-173709.png

I did not really get much sleep,

A lot of those centrals *MAY* be transition apneas if you had a really bad night.

Perhaps try sticking with the current settings for a few nights and see if you can get used to the single pressure?

[bonum.noctem]

Damned, so indeed Complex Sleep Apnea it is.

Positional sleep restrictions do not work for me, because OSA and hyopnea occur in all sleep positions with not being able to sleep on my back at all.

No point in hoping that this will get better on its own by suffering for an uncertain period of time with the wrong machine. I have just sent an email with these findings to my sleep clinic so that they can prepare an ASV machine for my next therapy night (which may still be months away due to not having been able to get an earlier appointment than end of March, 2019, but at least they have put me onto their jumper list).

I'm not sure what to do now. I guess at first I'll try to sell my ResMed AirCurve 10 VAuto as it clearly is of no use to me. Maybe I should try to find a deal on a used ResMed AirCurve 10 CS PaceWave, so that I have something to play with in the meantime.

Can a ResMed AirFit P10 nasal pillow mask be used with an ASV machine? Because ResMed seems to be recommending FFM for ASV, but I really would not want to use anything else than a P10.

[Pugsy]

You can use any mask you wish with the ASV machine and that includes the P10.
The Full Face Mask need thing was old school back when ASV machines had to learn the circuit. That ended with the S9 ASV type of models.

[Okie bipap]

It took about six month's for my wife's CA count to get to an acceptable level. They started her off at a lower pressure that cut her AHI in half. Her initial study said her AHI was 49, and when she first started treatment, her treated AHI was around 25. They would gradually add more pressure every month as the CA count would decrease. As soon as the pressure went up, the CA count would go up and then slowly decrease over a four week period. Since we last saw the sleep clinic June, her AHI has averaged 2.99 with the majority (2.17) being CA.

[bonum.noctem]

It took about six month's for my wife's CA count to get to an acceptable level. They started her off at a lower pressure that cut her AHI in half. Her initial study said her AHI was 49, and when she first started treatment, her treated AHI was around 25. They would gradually add more pressure every month as the CA count would decrease. As soon as the pressure went up, the CA count would go up and then slowly decrease over a four week period. Since we last saw the sleep clinic June, her AHI has averaged 2.99 with the majority (2.17) being CA.

And they didn't try her on ASV?

[Okie bipap]

Once she acclimated to the pressure changes, her CA events would go down. Then they would make a am a pressure increase and repeat the cycle until they reached the required pressure. They were trying to stabilize her CA events without resorting to an ASV machine. She had very few CA events during her initial sleep study. They did not show up until they did the titration study.

[bonum.noctem]

So here I am again, had my second therapy night in the sleep clinic last week and got my brand new ResMed AirCurve 10 CS-A PaceWave (seems to be identical to the AirCurve 10 ASV) with ClimateLine hose and AirFit P10 mask yesterday (brand new as in zero hours use, but it's only a rental machine for which my health insurance pays the rent as long as there is at least 80% compliance).

Here is the data from my first night on ASVAuto:

First night on ASVAuto

screenshot-20181204-135412.png (210.3 KiB) Viewed 11113 times

This seems to be a tremendous success, but I nevertheless did not sleep well. Maybe it just takes time to accustom myself to sleeping with mask and the way this machine influences breathing. The behavior of ASV is indeed a lot different from what I have experienced with the VAuto.

The current values have been set by the equipment provider according to the sleep clinic prescription. Do you see anything I should try to fine tune to improve my sleep quality?

[Pugsy]

From what I hear it can take some people a bit of time to get used to the ASV kind of machine's way of doing things.
I didn't when I tried one but then I had been on cpap/apap/bilevel for several years before I ever tried one and I adjusted easily to things by that time.

Now my first 3 to 4 months of apap therapy with my first machine...it was filled with wake ups just from having a mask on my face and some alien blowing air up my nose.

There can be an adjustment period getting used to any type of xpap. Let's face it...it's not exactly normal life.
Not to mention that people can have issues sleeping period that are unrelated to cpap/sleep apnea or type of therapy.

Give yourself some time for the brain to come to grips with the new "normal" in your life.

Nothing I would change in your settings as long as you are comfortable with them.
That one little group of hyponeas at the beginning of the night. Looks like 2 of them and I bet you were even asleep when those got flagged and thus aren't real and don't count.

[bonum.noctem]

From what I hear it can take some people a bit of time to get used to the ASV kind of machine's way of doing things. I didn't when I tried one but then I had been on cpap/apap/bilevel for several years before I ever tried one and I adjusted easily to things by that time. Now my first 3 to 4 months of apap therapy with my first machine...it was filled with wake ups just from having a mask on my face and some alien blowing air up my nose. There can be an adjustment period getting used to any type of xpap. Let's face it...it's not exactly normal life. Not to mention that people can have issues sleeping period that are unrelated to cpap/sleep apnea or type of therapy. Give yourself some time for the brain to come to grips with the new "normal" in your life.

Yes, what I have done previously was just playing around, but this is now serious business with daily use, so I'll stick to my routine and hope for the best.

The AirFit P10 itself is great and does not bother me at all. I think that mask clearly is the most unintrusive, it does not even touch my upper lip and I can even sleep on my belly with it (which is still my preferred sleeping position).

Nothing I would change in your settings as long as you are comfortable with them. That one little group of hyponeas at the beginning of the night. Looks like 2 of them and I bet you were even asleep when those got flagged and thus aren't real and don't count.

Yes, it took quite some time to finally fall asleep because I tried if I can do it laying on my back, which has never worked before and also didn't work last night, so those hyponeas must have occurred when almost (but unsuccessfully) falling asleep on my back before I turn to one side.

So I'll keep everything as is and am already excited for the next night. Although I didn't sleep well and didn't feel rested in the morning, I have omitted the after-lunch nap and nevertheless feel as having more energy than usual. Could be my imagination as well of course...