New APAP user. High central apneas.....Canada user

[Needsleep54321]

I started APAP therapy Jan 27, 2021. My in-lab sleep study showed on AHI of 72 (almost exclusively hypopneas). My AHI with the APAP is in the 20s. Mostly centrals (I didn't have centrals in my sleep study). So hypopneas have been replaced with central apneas. I am waking up constantly SOB and needing to breathe, with a low SPO2 (into the 60s and 70s and 80s). I called the sleep dr and have a couple of weeks before I can speak with him about this.

Pressure: 5-18
EPR: 3
Leaks: "happy face" on display.
Temperature: 21 (higher is too hot)
Humidity: 2 (higher is uncomfortable)
Location: Canada
APAP: resmed airsense autoset
Mask: Philip's respironics dreamwear under the nose nasal mask.

Why am I having all of these central apneas? Can I correct this? Is it dangerous that my oxygen goes low?

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[Pugsy]

How do you know your oxygen levels are dropping? Using an overnight recording pulse oximeter?

For now...assuming that you were actually asleep when all those centrals got flagged I have one idea for you to try.
You might get lucky. Various things can cause centrals to pop up when before they weren't a problem and using EPR (which creates a bilevel pressure situation) is one of them. Let's try easy fix first. If it doesn't work we talk more about it and cross that bridge if/when we come to it

Turn off EPR or if you just have to use it then set it for ramp only and make use of your ramp.
Your starting pressure is 5 cm...which is actually quite low in the grand scheme of things and you should be okay without EPR but if you can't do without...set it so it's only on during ramp and then set your ramp time to approximate how long it takes you to fall asleep.

Do you know how to change the settings and get into the clinical setup menu area?
If not it is explained in the manual here.
https://www.respshop.com/manuals/ResMed ... %20her.pdf

[Needsleep54321]

Thank you for your reply. Can it be dangerous or make my breathing worse if I turn off the EPR?

(It's a recording oximeter. A while back, when I asked my family dr for a sleep study, he said I just had anxiety. I got the oximeter to show him I did have a problem. He thinks everything is anxiety.)

[Pugsy]

Can it be dangerous or make my breathing worse if I turn off the EPR?

Absolutely NOT.

If anything it might just fix your issues in a quick easy step. I am crossing my fingers it will.

EPR is for comfort only...and people's use of it at whatever setting is a personal choice. Turning it off won't hurt a thing and it might just help a lot.

[Needsleep54321]

Thank you so much for your help. I really hope it's an easy fix like this.

[Needsleep54321]

I turned off the pressure relief setting (as suggested earlier). Here is my data from 1 day with that. I'm exhausted but can't sleep more to get data. I basically just repeatedly drift off to sleep then almost immediately wake up SOB. Over and over. It has been this way for months. Do most people sleep through these events? I thought turning off EPR might reduce the centrals, but I'm still having problems. I don't know what to make of this information. Do you know what it means or how I can improve it?

ETA: without the EPR on, I'm getting air in my stomach which is causing heartburn. I will deal with this if it means I can sleep. Just fyi.
Also, I will definently keep using the machine. I have a couple of weeks before I can speak with the sleep dr.

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[Pugsy]

Oh crap, didn't get lucky.

There are some people who develop complex sleep apnea once they get started on cpap and that means they add central sleep apnea to the obstructive sleep apnea diagnosis which makes it complex sleep apnea.

Sometimes turning off EPR resolves the issue but that only works if the bilevel pressures that EPR creates is the trigger for the centrals.
In your case it is not the trigger so turning EPR off doesn't help.

This is all assuming that you were asleep when those centrals were flagged.
The belly issues from the pressure without exhale relief have obviously compounded the problem.

Unfortunately there are centrals being flagged with pressures not up around the higher but at lower pressures...if you were asleep between 05:00 and 06:00 where the pressure was less than 9 cm.

Next thing to try.....reduce the maximum to 9 cm and see what happens.
Actually auto mode sometimes is not the best option for people with centrals.
Maybe try minimum of 7 (to help deal with the hyponeas) and max of 9.
I know the flow limitations are probably driving the pressures up but at this point the FLs are a less of an issue than the centrals are an issue.

You really need to be seeing your doctor. Don't cancel that appointment.
I suspect you are going to need a different kind of machine. What we call ASV and it can deal with both the obstructive sleep apnea and the centrals that get caused by treated the OSA with cpap.
https://www.resmed.com/en-us/healthcare ... ve-10-asv/

[Needsleep54321]

Thank you so much for your help. Do I turn the epr back on? Will my dr be upset that I'm changing settings?

[Pugsy]

You can turn EPR back on if you wish but I am hoping that with lower settings you won't need it and the belly issues won't be a problem.
I would try one night with the lower pressures and no EPR and then if belly issues continue...turn EPR back on.

as far as your doctor....it depends on the doctor but he should have been watching you much closer and not let this go since July.
Reducing pressure is less likely to cause them to get their panties all in a wad though. If he bitches tell him you had to try something because your sleep was crap and he wasn't available to help. As far as increasing the minimum...heck, the machine is doing that on its own anyway. Look at your pressure graphs..it goes up and stays up pretty much anyway.

There are some people who develop complex sleep apnea that find that it fades away with some time. You weren't that lucky...if it was going to happen there has been more than enough time since July for that to happen.
So some docs will "give it time" but in your situation you have already given it more than enough time and it didn't work.

[Needsleep54321]

I just started Apap therapy Jan 27 this year. It's been a few days. Sorry for the confusion. Should I be giving this more time? It doesn't feel safe to let it continue longer. I'm so tired.

[Pugsy]

Sorry I misunderstood time line.

Keep the appt in 2 weeks for sure.

Do you happen to have one of those overnight recording pulse oximeters? I am worried that the number of centrals you are having could be causing drops in oxygen levels to the point that it is potentially harmful. A few centrals here and there are no big deal but when you have a truckload of them back to back for a prolonged period of time then it can cause problems.

The give it time thing works better when the Complex Sleep Apnea (CSA) is running up around 10 ish central index....20 centrals per hour index...that's a lot harder for "give it time" thing to work successfully.

I assume no meds that might be suppressing respiration....especially pain meds????

I know if that were my report I would be pushing for ASV...the beauty of that machine is that if you don't have any centrals then all it does is deal with the obstructive apnea stuff BUT if you do have centrals pop up then it can force you to breathe.
I have used ASV just for grins. I don't have a problem with centrals other than an occasional normal central but when I did the ASV did its job. Otherwise it simply worked like an apap machine and auto adjusted as need for my OSA stuff.
You are in Canada and I have no idea what all is involved for getting ASV and whatever insurance you might have available.
I know each province is different.
If you don't have insurance....check out secondwindcpap.com for prices. They will ship to Canada and not require RX to be on file.

[Needsleep54321]

I'm not on any meds that would suppress breathing. Just thyroid and asthma meds. My spo2 dips anywhere from the 60s, 70s, and 80s through my sleep. I continually wake up and catch my breath and it goes back up to the 90s. It's scary because it's been happening for a while. I don't want brain damage. I'm on disability and so any machine should be covered. Yesterday the respiratory therapist mentioned trying a bilevel next. From my understanding, my current machine is a bilevel (ipap/epap). And a bilevel doesn't help with central apneas. Just wasted time to try a useless machine for me.

[Pugsy]

Bilevel itself just means 2 distinct pressures...one for inhale and one for exhale and when you use EPR (or any form of exhale relief) you are creating a bilevel situation.

Now there are several kinds of bilevel machines that do different things for different situations or needs

There is what I call the plain bilevel which is essentially pretty much what you are using now but think of it as being able to go higher than 3 cm with the difference between inhale and exhale. On those machines it is called pressure support. 3 cm pressure support is essentially equal to 3 cm reduction with the setting of 3 for EPR. It's set or figured a bit differently but the end result is essentially the same function.
EPR comes off of maximum inhale pressure (IPAP) to give you the drop to exhale (EPAP) pressure.
Pressure support (PS) is added to EPAP to give you IPAP.
End result is the same.

A regular bilevel machine won't be able to deal with central apneas in most cases. To deal with a central apnea the machine needs to be able to increase the pressure support rapidly and in a large amount. Like in a breath because that big PS forces you to breathe. It actually ventilates you and that's why ASV is considered a NIV or non invasive ventilator....non invasive because no surgery is done to the body. No trach to install and all that.
Some bilevels will give you a huge PS with every breath and won't auto adjust and for some people that is needed but for people like you who have centrals sometimes and not other times...kinda overkill plus big PS with every breath often will also trigger centrals.

The regular bilevel doesn't have a back up rate capability either...meaning it still basis what it does on your own breathing and can't force you to breathe if you aren't breathing. A central apnea is just no air flow because there is no effort to breathe. The brain doesn't send the signal to breathe. It's actually carbon dioxide levels in the blood that drive the brain to send the breathe signal. People often think it is oxygen levels but it's not. It's carbon dioxide that the brain monitors.
Hold your breath for 15 seconds....that's essentially a 15 second central apnea. No air is moving but because there is no effort.
Not a big deal when done randomly but when done back to back when you are asleep then obviously oxygen levels can drop.
A few centrals here and there...no big deal but when present in large numbers not only do they cause oxygen desats they also mess with sleep itself. They cause you to keep bouncing out of sleep so you don't ever really get the nice normal progression of sleep stages and you don't get the needed percent amount in each sleep stage for the restorative powers of sleep to work their magic.
I am betting you rarely get any REM stage sleep.

It's no wonder you feel like crap.

Since no centrals were found (or not enough to matter) during the in lab sleep study and now you are having truckloads of centrals then your centrals are caused by the cpap therapy. About 10 to 15 percent of the people put on cpap will develop complex sleep apnea just from cpap pressures. You drew the short straw.

You will most likely need a bilevel that has a back up rate available so that it can force you to breathe when you don't breathe on your own. I don't see a regular bilevel working well even with maybe a 4 or 5 PS. Typically a PS of 10ish is needed to force a breath and you don't want to use 10 PS with every breath. It's uncomfortable for one thing and will likely cause a carbon dioxide imbalance that will end up worsening your centrals instead of helping reduce them.

Unfortunately a regular bilevel is often the first thing that is tried and then when it doesn't help then docs will go to ASV or something with a back up rate. ASV has a back up rate ...and it will treat the OSA stuff just like the apap will and it ONLY deals with the centrals if/when they happen. It's a better option than having a backup rate high PS with every breath IMHO.
Now if your primary diagnosis had been central apnea and not obstructive apnea....then that's a different story.
You can see that sometimes you don't have a truckload of centrals so sometimes you don't need that back up rate.

You will have to jump through whatever hoops that are required to get a machine that can and will deal with your problem.
I have no idea what those hurdles might be. Here in the US it often depends on the doctor and various insurance requirements.

If you can all your doctor's office and push to be seen sooner...that's an option but unless he gets a cancellation..long shot.
You can try though. Call them up Monday and explain that you are having major problems and need to be seen sooner and ask to be put on cancellation list.

[Needsleep54321]

I can't tell you how much I appreciate your help. I would never have figured this out on my own. Thank you.

[MaskMan8888]

A couple of things to note about the Central recorded by CPAP machines is that often times they are not true central apneas. You will need to verify using an overnight oximeter or through a titration study in a lab to determine the nature of those events. The CPAP machine records any irregularities in breathing especially if you wake up frequently as central apneas; a flaw of the system. The other thing I noticed is that it is happening with you tracing is that it happens when your pressures increase. If you keep your CPAP pressure below 10, it may also reduce the central apneas. Hope that helps!