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Nezil
Unread post  Post subject: New CPAP User - Hi + Newbie Questions  |  Posted: Mon Oct 28, 2019 12:53 pm

Joined: Mon Oct 28, 2019 12:22 pm
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PAP Mask: Dreamwear Nasal Medium Frame, Small Cushion
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Pressure Setting: Currently experimenting! (12cm CPAP was prescribed)

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Hello everyone. I'm new to CPAP and new to this forum. In case it's relevant, I'm a 40 year old British male, but I currently live in Silicon Valley, California. I was diagnosed with Sleep Apnea about 3 months ago, after meeting with a sleep specialist because my wife was complaining about my loud snoring.

Once diagnosed, it took what seemed like forever to actually get a machine, but I now have an AirSense 10 AutoSet and a Respironics Dreamwear Nasal mask.

My doctor prescribed 12cm H20, and this is how the unit was set up at my provider. Having said that, since being diagnosed, I've started swimming every other morning, and my GERD and I believe Apnea have significantly improved. My provider also set EPR on at 3cm.

My first night at home was Friday, and I had 15.65 events per hour, quite a bit of aerophagia, and I woke up several times. Studying the data in OSCAR, I can see that the vast majority of these events were Central, rather than Obstructive, and that I had what looked like a lot of CSR, particularly later in the night.

Based on that data, I switched from fixed 12cm to Auto between 7 and 12, and this dropped my AHI down to 7.84 and totally removed aerophagia. The highest pressure seen was 10.72, but these dropped down to 7.0 many times. Although dropping to 7.84 is better than 15.65, there were still many many Central events and quite a bit of what looks like CSR.

Last night I reduced the ESR to 2cm, and got an AHI of 9.07. Overall pressure averaged lower last night, but I still had quite a few Central events and periods of CSR , though they seem to be shorter in total duration.

I'm therefore looking for advice on how I should proceed. I get the sense that my condition is currently not that bad, but I don't like seeing all of those Central events and CSR sessions.

I also wonder if there is a time required for the body to get used to CPAP, and if simply looking at a single night in isolation is enough to start making adjustments. Clearly the as-prescribed fixed 12cm is overkill for me currently and causes aerophagia, but I'm tempted to even lower the auto settings further to try and reduce the central events.

Any help would be greatly appreciated; thanks in advance!


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Pugsy
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Mon Oct 28, 2019 3:04 pm
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Turn off EPR totally and see if the centrals reduce.


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Nezil
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Mon Oct 28, 2019 9:13 pm

Joined: Mon Oct 28, 2019 12:22 pm
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PAP Mask: Dreamwear Nasal Medium Frame, Small Cushion
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Pressure Setting: Currently experimenting! (12cm CPAP was prescribed)

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Pugsy wrote:
Turn off EPR totally and see if the centrals reduce.


Thanks, will try this tonight and see how I get on. Stand by for a report tomorrow morning!


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Nezil
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Tue Oct 29, 2019 9:30 am

Joined: Mon Oct 28, 2019 12:22 pm
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PAP Mask: Dreamwear Nasal Medium Frame, Small Cushion
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OK, so as suggested by @Pugsy, I turned EPR off last night, and my AHI dropped to 5.65. A step in the right direction for sure, but there is still quite a few Central events, and looking at the flow rate I'd say that there isn't actually any Obstructive events at all; they're actually Centrals that have been mis-identified. There is also a period just before I woke identified by the machine as CSR.

Looking at the pressure at the time of each of the 33 Central events, I calculated the following statistics:

  • Min - 7.36
  • Max - 11.29
  • Average - 9.03
  • Median - 8.95
  • % of Central Events with Pressure above 8 - 91%
  • % of Central Events with Pressure above 9 - 40%

My very limited intuition tells me that perhaps I should try lowering the max pressure. If the pressure being too high is the cause of these Central events, lowering the max to 8 would eliminate 91% of these events. Does this seem reasonable?

To summarise my experience so far, the high level results are:

  • Static 12cm, EPR 3 - 15.65
  • Auto (7 ~ 12cm), EPR 3 - 7.84
  • Auto (7 ~ 12cm), EPR 2 - 9.07
  • Auto (7 ~ 12cm), EPR Off - 5.65


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Pugsy
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Tue Oct 29, 2019 10:25 am
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Sometimes its not a question of the pressure being "too high" that causes central apneas to pop up. Sometimes it is any cpap pressure...even 4 cm.
All this is of course assuming that the centrals are real asleep centrals and not awake breathing getting flagged by mistake.

Watch the videos here....especially the last one.
http://freecpapadvice.com/sleepyhead-free-software

What was your central apnea index last night? I know 33 total but I don't see a mention as to how many hours.

Do you take any medications? If so, what?


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Nezil
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Tue Oct 29, 2019 10:50 am

Joined: Mon Oct 28, 2019 12:22 pm
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PAP Mask: Dreamwear Nasal Medium Frame, Small Cushion
PAP Machine: Resmed AutoSense 10 AutoSet
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Pressure Setting: Currently experimenting! (12cm CPAP was prescribed)

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Pugsy wrote:
Sometimes its not a question of the pressure being "too high" that causes central apneas to pop up. Sometimes it is any cpap pressure...even 4 cm.
All this is of course assuming that the centrals are real asleep centrals and not awake breathing getting flagged by mistake.

I'm happy to share the actual sleep data if there's a way to get it out of OSCAR, and you'd be prepared to take a look.

Quote:
Watch the videos here....especially the last one.
http://freecpapadvice.com/sleepyhead-free-software

Thanks, I will do.

Quote:
What was your central apnea index last night? I know 33 total but I don't see a mention as to how many hours.

According to the machine, the Central index was 4.33, but I believe that all of the events were actually central and not obstructive, so 5.65 is a more accurate central index I think.

Quote:
Do you take any medications? If so, what?

Pantoprazole 20mg for GERD, taken first thing in the morning.


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Pugsy
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Tue Oct 29, 2019 11:05 am
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Joined: Wed Aug 02, 2017 8:01 pm
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PAP Mask: Bleep/DreamPort nasal mask
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ResMed is not well known for calling a flagged event by the wrong category. Not impossible for it to happen but it's fairly rare.

Here's something I put together on another forum to help with sharing what you see on the detailed reports so that we can see it.

You can do attachments here...so do a screen shot and then use the attachment feature here to upload it so we can see what you can see.

http://www.cpaptalk.com/viewtopic/t1585 ... eview.html

We don't want all the graphs. Just the basics and you can get all we need in one image. If we want something else we can ask.

Also can you zoom in on an episode of CSR flagged event breathing?
Maybe a 2 to 3 minute zoomed in segment.

I am NOT saying that all your centrals aren't real. I just want to be sure that what might seem worrysome warrants worrying about at this time.

Do you know if you had any central apneas show up on your diagnostic sleep study?


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Nezil
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Tue Oct 29, 2019 12:00 pm

Joined: Mon Oct 28, 2019 12:22 pm
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PAP Mask: Dreamwear Nasal Medium Frame, Small Cushion
PAP Machine: Resmed AutoSense 10 AutoSet
Humidifier: Integrated
Pressure Setting: Currently experimenting! (12cm CPAP was prescribed)

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Thanks for looking into this for me @Pugsy.

Here are the screen captures you requested:

Image

Image

Quote:
Do you know if you had any central apneas show up on your diagnostic sleep study?


I had two sleep studies done, the first was an at home study, which provided this data:

SLEEP/MONITORING TIME DATA:
Recording start time (hr:min): 11:40 pm
Recording end time (hr:min): 7:38 am
Total recording time (TRT): 478 minutes
Monitoring time (MT): 438 minutes
(MT is total recording time minus periods of artifact and time the patient was awake as determined by respiratory pattern)


RESPIRATORY ANALYSIS:
Respiratory Event Index (REI): 50.7
(REI=AHI based on monitoring time)
*REI 4% or greater: 47.2
Supine REI: 75.9
Time in Supine (hr:min): 4:21
Non-supine REI: 13.6
**Body position cannot be verified

Obstructive apneas (index): 22.4
Mixed Apneas (index): 2.1
Central Apneas (index): 11.8
Hypopneas (index) : 14.5


OXYGEN SATURATION:
Minimum monitoring SpO2 (oxygen saturation): 76%
Monitoring Time with SpO2 < 88% (min, % of MT): 29, 7 %

HEART RATE (HR - bpm):
Average HR: 59
Highest HR: 99
Minimum HR: 45


The second was an overnight study at the sleep disorder facility, which yielded these results:

CPAP settings of 5 to 15 cm of water were used during the titration

SLEEP SCORING DATA:
Lights Out / On (clock times): 23:03:39 / 06:13:40
Total Recording Time (TRT) (min): 526.5
Total Sleep Time (TST) (min): 416.5
Sleep Efficiency: 96.9%
Sleep Latency (min): 12.0
Stage REM Latency (min): 65.0
Wake after sleep onset (WASO) (min): 1.5

Stage N1 Sleep (min, % of TST): 13.5 (3.2%)
Stage N2 Sleep (min, % of TST): 145.5 (34.9%)
Stage N3 Sleep (min, % of TST): 165.5 (39.7%)
Stage R Sleep (min, % of TST): 92.0 (22.1%)
Supine Sleep (min): 139.0
Arousals (index, #): 19.3 (134)

RESPIRATORY ANALYSIS: (index = #/hr)
Apnea/Hypopnea Index (AHI): 16.4
*AHI 4% or greater: 4.5
NREM AHI: 17.9
REM AHI: 11.1
Non-Supine AHI: 16.6
Supine AHI: 16.0

Respiratory Disturbance Index (RDI): 17.1
NREM RDI: 18.5
REM RDI: 12.4

Apneas (index, #): 4.5 (31)
Obstructive Apneas (index, #): 0.0 (0)
Mixed Apneas (index, #): 0.9 (6)
Central Apneas (index, #): 3.6 (25)
Hypopneas (index, #): 12.0 (83)
RERAs (index, #): 0.7 (5)

Mean Awake SpO2: 97%
Mean Sleep SpO2: 96%
Minimum Sleep SpO2: 93%
Sleep Time with SpO2 < 88% (min, % of TST): 0.0 (0.0%)

Cheyne Stokes breathing: No

CARDIAC ANALYSIS:
Mean Awake HR: 55
Mean Sleep HR: 55

Bradycardia: Yes
Asystole: No
Sinus tachycardia: No
Narrow Complex Tachycardia: No
Wide Complex Tachycardia: No
Atrial Fibrillation: No
Other: None

LIMB MOVEMENT ANALYSIS:
Periodic Limb Movements of sleep (PLMS) (index, #): 5.8 (43)
PLMS with arousals (index, #): 0.3 (2)

OTHER ABNORMALITIES:
No other unusual body movements were demonstrated and no seizure activity was noted.


So yes, Centrals did show up.


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Pugsy
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Tue Oct 29, 2019 12:42 pm
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Okay....some centrals in both sleep studies but not an alarming number.
The period of CSR flagged stuff....any chance you were in and out of sleep when that got flagged?
It doesn't look classic CSR to me. Looks more like some arousal irregular breathing to me.

I don't think your centrals are related to pressure at all. You had a few even at home on the diagnostic sleep study with no pressure.

At any rate...for now the doctors wouldn't do anything about them except keep an eye on them even if every single central was a real asleep central.

It is possible that they hyponeas you see flagged at approx the same time frame as the central flag are causing an arousal of some sort and the arousal gets the irregular breathing flagged by mistake.

If you would feel better limiting the max just to see what happens with the centrals...by all means give it a try. Your OAs or hyponeas might increase though.

Finally sometimes even when cpap pressure is the cause of centrals a person can eventually "grow" out of it with some time on cpap once the body gets a chance to adjust to cpap therapy. This is why doctors don't get in a big hurry to do anything about centrals when someone first starts therapy especially when the number of them is in single digits per hour average.

At this point if this were my report I would concentrate on sleep quality and trying to reduce any wake ups that I might be having. Don't spend a lot of time with the mask and machine on and you are awake.

EPR does trigger centrals in a very small percent of people using any form of exhale relief because using exhale relief causes a bilevel pressure situation and for some people bilevel causes centrals. It's really odd because usually the first thing that gets tried to reduce centrals when they are too numerous is a plain bilevel machine...but for some people that makes things worse. I am not sure if you are one of those people yet or not. Your centrals could just be a reflection of some awake or arousal breathing getting flagged by mistake.

Our awake breathing is very irregular when compare to asleep breathing and the machine has no way to know if we are asleep or awake. All it measures is air flow and sometimes the machine flags awake breathing by mistake. I have it happen all the time because I have a lot of wake ups during the night due to pain and other issues.
I had a night a while back where the AHI was 3.5 and every single flagged event was related to arousal/awake breathing. Not a single event was flagged when I was really asleep.
Sometimes a higher AHI is just a symptom of crappy sleep. The night that I had that higher than usual AHI....really bad night for me in terms of pain. I slept horribly that night. Lots of tossing and turning due to pain.


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Pugsy
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Tue Oct 29, 2019 12:43 pm
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Oh....a few centrals here and there that are real asleep centrals are normal to have. Everyone can have them every now and then. Not a big deal.


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Pugsy
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Tue Oct 29, 2019 1:58 pm
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Here's some images of real CSR and of the magnitude where we worry about a person.

Image

Image

Image

Image


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Nezil
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Wed Oct 30, 2019 9:02 am

Joined: Mon Oct 28, 2019 12:22 pm
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So I got home a little later than usual and didn't bother to change anything at all... and this was last night's result:

Image

I guess it could very well be that it's taking time for my body to get used to CPAP treatment. I think I still prefer auto rather than a fixed 12 cm pressure, simply because 12 is quite strong and makes exhalation a little difficult.

For now, I'm going to keep things as they are and see how it goes for a week or so I think.

Thanks for your help and feedback so far @Pugsy!


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Nezil
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Wed Oct 30, 2019 9:08 am

Joined: Mon Oct 28, 2019 12:22 pm
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PAP Mask: Dreamwear Nasal Medium Frame, Small Cushion
PAP Machine: Resmed AutoSense 10 AutoSet
Humidifier: Integrated
Pressure Setting: Currently experimenting! (12cm CPAP was prescribed)

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Oh, and I did mean to mention this:

You may be correct about waking up. I know that ever since starting CPAP I am aware that I'm waking slightly more than I perhaps used to. I fall right back to sleep, but usually turn over or something before doing so. It's a little annoying but not terrible.

I'm not sure at this point if the waking is caused by an apnea or something to do with not being used to CPAP. One thing I can say is that before CPAP I don't remember waking hardly ever, even though I probably did. I'm therefore inclined to think that using CPAP may make me more aware that I have woken, because of the feel of a mask on the face and the different feeling when breathing.

I also might be a little unusual in that I never really felt that my apnea was problematic for me. As I said, I never remembered waking up, and I didn't feel that tired day to day.

The only major reason I even sought treatment at all was because my wife kicked me out of the bedroom because I was waking her and ruining her sleep with my snoring and gasping!

So for me... CPAP has allowed me to sleep next to my wife again in my own bed, and that's a huge benefit!


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Pugsy
Unread post  Post subject: Re: New CPAP User - Hi + Newbie Questions  |  Posted: Wed Oct 30, 2019 2:54 pm
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You know there is a lot of truth to the "give it time" adage.
People tend to be impatient and forget that all this takes time for the body to adjust to.

Hurts nothing to give the body time to catch up.

It took me 3 full months before my brain quit poking me and waking me up just to tell me that I either had an alien plastered on my face or to tell me that I was so used to the pressure that the brain thought the machine was off.


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