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AHI numbers are good, but still have concerns (long apneas & flat looking flow lines)
#1
AHI numbers are good, but still have concerns (long apneas & flat looking flow lines)
About a month ago my teenage son's doctor raised his pressure from 6 to 9, and his AHI has averaged about 1.3 since the change. While his numbers look good, on some mornings he looks pale upon waking and doesn't feel well rested. One thing I have noticed is on occasion he will have apneas that last a long time. Approximately once a week my son removes his mask while he his sleeping. I have noticed a long flat line often proceeds him removing his mask. This screen shot is typical of this scenario, 2 minutes and 14 seconds elapse from the time the flow line flattens until he removes his mask.
[attachment=7086]
Another long apnea (1:55) that didn't result in him removing his mask. 
[attachment=7087]
These long apneas are not the norm I only see about 1 a week, but 2 minutes seems like a long time to go without breathing. Are the long apneas something I should be concerned about?

My next question is about a flat looking flow line I often see. His inspiration and expiration are so close to the zero line which makes me wonder how he could be getting enough air. When I see this flat looking flow line the machine often doesn't flag anything. This shallow looking breathing shows up nearly every night and often lasts as long as 5 minutes. Does anyone have any thoughts on what might be going on here?
This is an overview of last night:
[attachment=7088]
The flat waveform that concerns me:
[attachment=7089]
A more typical breathing pattern from earlier in the evening. 
[attachment=7090]


My son has an appointment soon with his sleep doc/ pulmonologist soon and I'm trying compile data to share with his doctor. Thank you to all who have given me input on previous posts, as well as to everyone who contributes to this forum, it is such a tremendous resource!
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#2
RE: AHI numbers are good, but still have concerns (long apneas & flat looking flow lines)
Hi ColoradoMom,
I can't say I can tell you exactly what is going on with your son's waveforms but there are issues with sensors on a nasal mask when some of the flow may be going through the mouth.
A more knowledgeable poster explains more about it here and coments:
"Flow Rate waveforms generated while wearing a nasal mask can be confusing. "

I can't post the link because it points to a DME owned site. If you search for it using the following it can be found easily.

Flow-Rate-Waveform-Examples-using-a-Nasal-Mask
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#3
RE: AHI numbers are good, but still have concerns (long apneas & flat looking flow lines)
Thanks for your input Mogy! The waveform examples you mention are really helpful. It didn't occur to me that a nasal mask may not always pick up all of the flow due to mouth breathing, but it makes perfect sense.
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#4
RE: AHI numbers are good, but still have concerns (long apneas & flat looking flow lines)
I would suggest a full face mask, I’ve been using one for 15 years. Since this is a kid, tell him/her that fighter pilots wear them, so they may accept it better.
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#5
RE: AHI numbers are good, but still have concerns (long apneas & flat looking flow lines)
(06-30-2018, 07:47 PM)ColoradoMom Wrote: Thanks for your input Mogy! The waveform examples you mention are really helpful. It didn't occur to me that a nasal mask may not always pick up all of the flow due to mouth breathing, but it makes perfect sense.

ColoradoMom, aren't you still monitoring your son's oxygen saturation?  As you say, two minutes is an awfully long time to go without breathing and he should have had a strong reaction, or at least an OA recorded.  But if his O₂ sat plummeted, then it is serious.

mdhampton makes a good suggestion for getting your son to buy into using an FFM, though I suspect he's a bit too old/mature to be moved by that.  I think suggestions have been made to employ a cervical collar and/or chin strap – have you folks considered this?

It's great that his "numbers" are so good.  It's not good that he sometimes wakes feeling and looking bad.  I'm guessing that you haven't been able to see a correlation between his charts and his appearance/feelings.  What you've described seems much more than the typical fluctuations we experience as our therapy begins effecting changes.  Especially the paleness sounds grim – what are his O₂ sat numbers on those mornings?
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#6
RE: AHI numbers are good, but still have concerns (long apneas & flat looking flow lines)
Thanks for the suggesting the full face mask mdhampton, it's certainly worth a try! 

Thank you Shaun for your input! I've tried talking my son into the cervical collar, but he isn't willing to try it. Despite being a teenager my son has done great with the CPAP! He wears the mask every night, even on nights when his buddies sleep over. The cervical collar is just to much for him, but we are looking into finding a pillow that could serve a similar function. 
I haven't been able to get on overnight oxygen reading for quite some time. My son is a really restless sleeper and no matter how well we tape the sensor on lately he has been ripping it off in his sleep. When I check his O2 after he wakes up on days he looks pale it has been 90-92%. I feel have seen a correlation between his charts and the way he feels the next morning. Most of the times I have seen long apneas he ends up removing his mask in his sleep. He feels bad the next morning following the long apneas, but it's hard to say if that is because the long apneas are real, or if it is because he was without CPAP for most of the night. I also feel like there is a correlation between the prevalence of the flat looking flow lines I inquired about and the way my son feels in the morning.
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#7
RE: AHI numbers are good, but still have concerns (long apneas & flat looking flow lines)
A very good chin strap might help if he rejects the Full-faced mask as they can be a bit claustrophobic.
Get a chin strap that goes over the head from the chine and round the back of the head, you can get these from Ebay for a few $ but it is a bit of a hit and miss as to their quality. They need to be tight from the chin over the head, then held in place by the strap going round the back of the head. I found these to be very good, if you do send for these, take note of the sender and they do vary a lot in quality as I found out.
Have a look for them and if you have a supplier near you go try them, though it will be more expensive from them.
A good investment for your son might be an oxygen monitor, just to see how much his oxygen levels drop or not during the night.
I am NOT a doctor.  I try to help, but do not take what I say as medical advice.


Every journey, however large or small starts with the first step.

Sleep-well
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#8
RE: AHI numbers are good, but still have concerns (long apneas & flat looking flow lines)
ColoradoMom, a thought just occurred to me that your son may find acceptable: some forum members have discussed using inexpensive cameras to record their sleep and comparing their arousal, movements, and positions with their SH charts to possibly identify causes/triggers of events.  I've considered doing this but haven't progressed to a decision-making point and have no specific information to share.  I do believe there were comments of devices in the fifty- to seventy-five dollar range.

If your son could see evidence of events being triggered by something like position, mouth-breathing, etc., he might be more willing to try a cervical collar, mouth-taping, etc.

FWIW, I finally bit the bullet and bought a cervical collar (which I found very uncomfortable) and after a week or so have adjusted to using it and I've seen a huge improvement in my Large Leak numbers, and maybe a small improvement in my events.  (Events were already very good and sometimes awesome, but the leaks have been a problem.)  Though I have no idea what causes your son to take the mask off or wake feeling bad, logical remedies to explore include collars, chin straps, and mouth taping – all of which are intrusive, uncomfortable, and usually quickly accommodated.)

Hope that helps!
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