Sierra

I am told that you need to hold two fingers on the screen of an A11 for about 4 seconds to get to the clinical menu on it. A change from the A10. If you are going back to visit your sleep doctor be sure to take your SD card in and ask them to look at the data. For discussion it would also be good to print out some of your OSCAR charts where you are having frequent CA events and sections where CSR is flagged. It is good to zoom right in where there are lots of CA events and CSR to show the detail of your flow rate. Include a graph of your Minute Ventilation. That can be telling too. And you can post it here for comments too.

That is interesting and very different from the CA patterns I experience. Now I am not so sure it is a control system problem. That said part of it may be, as those last 4 events on the second graph do have some similarities to mine and indicate a control system issue. As far as CPAP options about all I can see is further reductions down to 6 and possibly 5 cm. The hope would be that it would reduce CA without causing much of an increase in OA events. Beyond that, I think you are best to find a good sleep apnea specialist, and show them what you are getting for results. A central apnea frequency like you have is not really acceptable, and you need to get to the bottom of it. Acetazolamide which is prescribed for altitude sickness and is off label for central apnea treatment, has worked in some cases. You should ask about it when seeing a specialist. See this article:

The role of acetazolamide in sleep apnea at sea level: a systematic review and meta-analysis

Another kind of last resort option may be to investigate use of an Adaptive Servo Ventilation machine instead of a CPAP, They go beyond just using pressure to keep the airway open, and adjust inhale and exhale pressure on a breath by breath basis to maintain regular breathing. ResMed makes one called the AirCurve 10 ASV which looks very similar to your A10 machine, but operates in a much more sophisticated way. It essentially forces you to breath regularly. Phillips also make one that some claim is better. I have not done much research on them, as I have managed to solve my issues with just the regular A10 machine by using a fixed pressure of 11 cm, and adjusting my beta blocker med.

Here is an example of the zoomed in detail that would be helpful to look at. This is from a night where I had quick successive CA events. What you can see on the very left is that my breathing indicated by flow rate was reasonably regular. Minute Ventilation is a measure of how much air is being moved in and out. It was somewhat regular. But then at 6:36 there is a flow disruption. I may have woke up, or had a very brief obstructive event, but whatever it was it started a repeating regular cycle of deeper and deeper breaths and then shallower and shallower, until at some point they were so shallow it gets flagged as a CA event. And, then that repeats causing even more events. In my case I believe this is being caused by my cardiovascular system being too sluggish. Bisoprolol slows the heart rate, and I think cutting the dose of that in half helped bring my heart rate up and increase response. This can also be caused by heart failure, and I hope that is not the case, for either of us! The body depends on CO2 in the blood to determine if the breathing rate is too slow or too fast. But if the response from decreasing breathing rate is too slow the control system can go unstable. It is somewhat like being on cruise control and encountering a hill. The vehicle slows, and the control system applies more gas. But if the application of the gas is too slow you can get to the top of the hill and then there is too much gas for the needed speed. Basic control system instability. The big question is what is the cause of the instability. Alcohol and drugs like Ambien can impact the control system and possibly dampen it to make it stable.

I find the flow rate and minute ventilation the most important graphs in trying to figure out what is going on. If you could post a screenshot similar in layout and level of detail (zoom) to mine it would be helpful. Your underlying issues may not be the same as mine, but that screenshot should be telling.

I am not sure about the arousal level being a problem. I suspect most central apnea has a control system stability issue that is at the root of it. Looking at minute ventilation is the easiest way to see how stable the control system is working for you. Ideally this graph should be a nice smooth flat line.

It is a journey to find a mask that really works for you. Glad to hear you found one. I have looked at these masks and the very similar one from ResMed and wondered if they would work for me. I am using a hybrid mask with the ResMed AirFit P10 nasal pillow frame, but with ResMed Swift FX headgear. This works for me, but it is a bit of a pain to make the modifications to make it work.

Interesting that they have actually made some more changes in the A11 compared to the A10 than I was aware of. I had thought that the only significant change was the availability of the For Her mode in all machines.

I am in Alberta and wanted to buy an A11 for my wife, but it seems that the supply of CPAPs at the on line outlets is so reduced you have to put your name on a waiting list to even get an A10. I managed to find an AutoSet For Her A10 with only 96 hours on it, so we bought it instead.

I stumbled on this article in the blog section here that you might be interested in.

Oral Devices

For sure the central apnea frequency is an issue of concern. When you were diagnosed what was the breakdown of events in the sleep study? What was the total AHI, and of that how much was CA, OA, and H? The issue is that CPAP treatment pressure can cause the CA event frequency to increase. Here are links to a couple of articles about Central Apnea and Complex apnea (both obstructive and central). You should get yourself up to speed on what it is all about. You then should see your sleep doctor and/or regular doctor. I would print out those Daily reports where there are the high frequency of CA events to show them.

Central Sleep Apnea

Complex Sleep Apnea

There are a lot of potential causes including medications, heart conditions, living at a high altitude, etc and you should get to the bottom of it. High frequency CA events and CSR can be an indication of underlying health conditions. I noticed in that article on Complex apnea that some get benefit from sleep medications, which may be why you are getting some relief from alcohol. It probably would be much better to go the prescribed medication route rather than alcohol though. I have had central apnea issues and I take a beta blocker drug called bisoprolol. I got the dose reduced and I think it has helped me some.

I would be interested in seeing a zoomed in shot of an area where there are a high frequency of centrals. Just left click repeatedly in that area to zoom in. The arrow keys can fine tune the zoom.

The problem with alcohol is that it can relax you and help you in the early sleep but as it wears off you tend to wake up and everything gets worse after that. It would be much better if you could post a Daily Screenshot with this type off format in the example below, and I could give you my comments. Central apnea is difficult but there are some things one can do to control it.

Welcome to the forum. Some thoughts:

A proper sleep clinic should have ResMed software called something like ResScan. It is similar to OSCAR which frankly is an unauthorized knock off product developed as OpenSource freeware. If you take your SD card into your clinic they really should be able to look at the data and give you their analysis. Unfortunately most just want to sell you a machine and not have you come back unless you want accessories or a new machine. If you post your Oscar charts here I and others can give you their opinions. This is the format I like to see it in, so I can be most helpful. On a PC when you have the screen set up just push F12 and observe where the file gets saved. You can then drag it into a post here. Use a new full with window so it is easer to read.

Running a baseline with a CPAP is really not possible as these machines will not reduce pressure below 4 cm of pressure. A sleep study is done with zero pressure. Your machine will always be providing some kind of treatment. The other issue is that only 4 cm of pressure can be suffocating to sleep with. I see you seem to be starting your sleep each night with only 4 cm of pressure. That is unlikely to be very comfortable. My suggestion based on your two OSCAR charts is to increase your minimum set pressure to 7 cm, and set your ramp time to auto, and to set the ramp start pressure to 7 cm. That should give you a better start to your sleep each night. To do these things you have to go into the clinical menu. See this link for a Clinical Manual.

You do seem to be having some issues with CA events and CSR. This sometimes can be something called "treatment emergent central apnea". The pressure of treatment can be causing the CA events. Pressure can stop OA events, but can make incidence of CA events worse. The good news is that in most this effect goes away after about 6-8 weeks. For me it did not. I had to go through all kinds of changes to try and bring it under control. I used to get CSR quite reliably about once a month, but it has gotten better.

Hope that helps some. Post your Daily screenshots for more comments. Only post one at a time or your post may get hung up in the spam filter here.

To set the mode you have to go into the Clinical Menu by pressing and holding the round set button and the rectangular Home button at the same time for 5 seconds. With the A11 you should have a choice of the CPAP mode, AutoSet mode, and the For Her mode. You may have to use this menu to setup the ramp as well. Here is a link to a Clinical Manual that gives all these details for an A10 machine, Your A11 should be closest to the For Her A10. See pages 15 to 18.

AirSense 10 Clinical Guide

Also when in the Clinical Menu scroll down to Options, Essentials, and set it to Plus mode (if it not there now). That will give you access to more settings from the User Menu, and a more detailed Sleep Report on the machine.

There is no real benefit to eliminating the ramp when it is in auto. I agree that the timed ramp is an annoyance, but when the time is set to Auto it is not a problem at all. It automatically switches out of ramp when you go to sleep, which will happen quite quickly by the sound of it. I find it works really well for me.

Yes, there are lots of options to change to optimize your results, but it takes time to try them all to see what works and what does not. The other advantage of using the Ramp set to Auto is that it does not respond to or count events detected. In the first few minutes of going to sleep most have what is called by some as "Sleep-Wake-Junk". These are false indications of OA and CA events. they can mess up your data with no real value added.

Yes, with the VAuto the maximum pressure can be set as high as 25 cm. However, the pressure support (difference between IPAP and EPAP) has a maximum of 10 cm compared to the 3 cm on the AutoSet devices. So, it can give a much larger differential between inhale and exhale to assist in breathing.

Did you export the data to produce that graph? I don't seem to have anything quite like it in SleepyHead. Or, is it a feature of OSCAR?

I have looked at several days of my wife's graph for Flow Limitation and for my own. She has more of an issue with it than I do. From what I see, it sits mainly in the less than 0.3 range and peaks at about 0.5 occasionally. I set SleepHead to show the 95% dotted line, but I can't see any. Perhaps a bug in SleepyHead...

My machine is in fixed pressure CPAP mode by my wife's is still in Auto, but with a quite narrow range; Min 13.6, Max 14.4, and EPR at 2 cm. I should probably try hers at 3 cm to see if that helps or hurts. She just got a new A10 For Her and I thought I should let things settle a bit before trying any changes. Her average AHI is 0.45, so not pressing to make any changes. She used a S9 before that with the same settings, and a slightly higher average AHI of 0.52. This all said her pressures seem to get driven by flow limitations and less by OA or hypopnea events. I have never really tried to track our flow limitation values in any detail. My issues are high CA events, and hers is more OA events and trying to keep them down without going too high in pressure.

So, I am not sure if a BiPAP would help to reduce flow limitation values. It may. I believe they can go up to about 10 cm of "pressure support" which is essentially the same as EPR on our machines, but EPR of course is limited to 3 cm of pressure assist on inhale. For whatever reason BiPAPs refer to it as a pressure increase on inhale, while CPAPs call it a pressure reduction on exhale. Really the same thing, at least on ResMed machines.

I think the first thing I would try on your machine is tightening up the pressure range by increasing the minimum pressure. This may reduce flow limitations before they happen rather than waiting for them to occur and have the machine respond to them with more pressure. I would suggest 14 cm as a minimum, which is closer to where my wife's machine is. You could also probably reduce the maximum some, after you see what the increase in minimum does. Once you narrow down what pressure you really need, a trial at a fixed pressure (CPAP) may be worth a try. 15 cm fixed may work well for you or something around that.

The other possibility is a switch to the For Her mode. I believe the A11 machine includes that as an option. The For Her mode is supposed to increase pressure earlier to flow limitation and RERA. I have not tried it on my wife's machine as I recall that the For Her mode only uses up to 12 cm of pressure and that would not be enough for her (or you by the look of it). But you may want to look into it to see if 12 cm is really the max it uses.

Edit: Not sure from your graph that you are using the Auto Ramp feature or not. 14 cm is a bit high to go to sleep with, so if you adjust the minimum up to that, you should set the Ramp Time to Auto, and also set a Start Ramp Pressure to about 9 cm. That will be more comfortable in going to sleep. When the machine decides you are asleep it will ramp the pressure up to the minimum pressure.