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As Good as it Gets?
#1
As Good as it Gets?
   I am here to see if I can better understand my wife’s treatment that she has received with her CPAP for the last 6 months and whether she is actually benefiting from it’s use.

   She is 75 years old and has a heart arrhythmia (not A-Fib) as diagnosed by her doctor. I had noted that when she had minor nasal congestion and I could hear her sleep breathing I sometimes could hear her go through a 1-2 minute cycle where her breathing would seem to fade away to nothing, stop for 10-20 seconds, and then slowly begin again. It was very repeatable for 20-30 minutes. During this time she would rarely snore or be aroused.

   We live in a rural town. Rather than a PSG her doctor recommended a recorded oximeter for several nights. According to that study she had 30 events/hr. I don’t know the criteria of an event (less than 90% O2 saturation for 30 seconds?). She was rarely tired in the morning. She could often get a good night’s sleep but because of her arrhythmia the doctor decided to have her use a CPAP machine (ResMed AirSense 10 AutoSet for Her). The doctor has said it lowered her event rate. I’m not sure how he would compare an oximeter event rate to that of a CPAP.

   She went through a period of combating large leaks. Prefers sleeping on her stomach so would often dislodge the mask. She has used a full face mask for the last several months and is doing better leakwise.

   She also has an Apple Watch which has an ECG of sorts. It categorizes a 30 second ECG as “Sinus Rhythm”, “A-Fib”, or “Inconclusive”. Her measurements fall seemingly randomly in all three categories. The doctor has said that if it repeatedly falls in the “A-Fib” category to seek help.

   I have several questions:

   Because she never had a proper sleep study I wonder what her untreated baseline actually is.  For a couple of nights I set both the min and max pressures to 4 cm of H20. I’m assuming that doing so will make a CPAP machine only a passive monitor, not an active machine.  I wanted to see if the machine was actually making things better. Does doing so actually make a CPAP a passive monitor?
   Attached are 5 OSCAR charts. The first two are usual operating CPAP with min and max of 8 and 20 cmH2O. The second two are run with min and max of 4 and 4 cmH2O in “monitor mode”. The last image shows a 20-minute period of CSR. Is it really CSR or consecutive OA? There seem to be minor snores when OA’s are tagged. I’m new to trying to understand this.

   We often see tagged Cheyne Stokes Respiration (CSR). Is that something to be concerned about? CSR seems to be present some nights whether we use a significant pressure or not.

   She is running an AHI of 5-6 over the last month. The two nights we ran in “monitor mode” averaged an AHI of 6.5, not much difference. Is an AHI of 5-6 good? Can it be improved? Is the machine causing any improvement?

   Would love to hear comments.


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#2
RE: As Good as it Gets?
Welcome to the forum.
Think of the CSR stat as being PB or Periodic Breathing, that is what it is.  It is NOT CSR which is always a concern with users with heart conditions such as CHF but we always refer to a doctor when we see it and, again, it is not there.

The clusters of OA are indicative of the head tucking forward, the chin coming toward the chest.  They are usually eliminated with a sleep collar (similar to a soft cervical collar but without the back.

She has substantial Flow Limitations.  These could be impacting her breathing, making it more difficult to breathe.  This can be improved either with EPR fulltime, and EPR=3.  The EPR should also make it easier to breathe. 

I try the following settings

Min Pressure =7
EPR on Fulltime
EPR =3

The other possibility is that she shifts to a BiLevel such as the ResMed AirCurve 10 VAuto which has the capacity to achieve a higher pressure support or difference between Inhale and exhale pressure.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

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#3
RE: As Good as it Gets?
Unfortunately, your dear wife is almost certain to have to forego sleeping on her stomach.  It's not really good for her without apnea, or with the mask and device in place because she has it.

I used to be an inveterate stomach sleeper.  Then, I developed apnea and then developed Afib.  The grossly twisted neck that is necessary to breath while sleeping prone isn't great for breathing.  I think it's almost as bad as chin tucking.

I have only looked briefly at the first two charts you posted.  The AHI nightly average is not great, to be honest.  She will be able to get it down, but it won't be easy...not if she has to adjust to sleeping in a way she hasn't particularly liked in times past.  I side sleep quite easily....now...but it was a struggle at first.  The problem was dislodging the mask, and I also use the same mask, the N20.  Somehow I lost the desire to sleep on my stomach (still get the odd and rare urge, but it passes), and happily I can sleep on my side without incident.

We're going to try hard to get her typical night, with some minor variation, under 3.0, and I'd bet we'll eventually do better than that. Bonjour has suggested some remedies, and I agree with what he has said.
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#4
RE: As Good as it Gets?
Hi, Moabyte
very farway from as good as its gets... long way to go, and large room to improve!
Fred's start up looks proper!
Severe untreated UARS/Flow limitation appears more serious than apeneas themselves; brain asking to sleep on the stomach would be one of the most indications of UARS/Flow limitation severity.

Good Luck
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#5
RE: As Good as it Gets?
Fred and others,

   Thank you for your comments.  I know it's going to be hard to get her off her stomach.  She starts in the evening on her back but just ends up flipping later.  We did change to the EPR mode as you suggested and now the graph of "flow limit" now looks like short grass instead of tall grass.  It's my understanding that that is a comfort setting that makes it easier for her to breath but does not really reduce apneas.  It may make it easier to breathe and thus she will get a more restful sleep???  Attached is here latest Oscar detail and it shows the pressure increasing to stem OAs at 21:50, 2:15, and 3:00.  But should we not be concerned that, over the last two days anyway, 3/4 of here events are CA and only 1/4 OA?

Moabyte


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#6
RE: As Good as it Gets?
There are some things I find confusing. On September 10, the screenshot shows the pressure is set to 4 minimum 4 maximum, and of course the results are miserable. September 7-9 are set at 8 minimum 20 maximum, and we see a clearcut clustering of obstructive events. Bonjour's suggestion of a soft cervical collar is right on.

Here is my take. Your wife with a pressure of 8 to 20 has incredibly high flow limitations all the way through the session. This suggests she would benefit from both a comfort and therapeutic standpoint with exhale pressure relief (EPR) being turned on. This allows the machine to lower pressure during exhale by 1 to 3 cm pressure. So if we start at 8.0 and use EPR 3, her starting pressure is 8 inhale and 5 exhale. If we treat the flow limitations we can really cut into the hypopnea, RERA and keep the machine from increasing pressure so high. Actually her pressure is being limited to 12 by the "for her" mode.

We also need to keep her from letting her chin tuck to her chest. That is what causes the big clusters of obstructive apnea. No pressure can open an airway closed due to a sleeping position that physically closes the airway. Read the Soft Cervical Collar link in my signature and learn more about positional apnea. Since your wife sleeps on her stomach, the neck flexion may be to the side instead of chin to chest, so that may be something to consider.

I recommend turning on the comfort feature EPR to a setting of 2 or 3 and starting at a pressure of 9.0. I think she will find this much more comfortable. The clusters of OA will require dealing with physical closure of her airway. Pay attention to her head and neck positions, and any sharp angles will reduce airflow. Chin tucking is what we see most often.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: As Good as it Gets?
  To answer your question when you said you were confused by the settings of minimum = 4 and maximum = 4, we were trying not to treat any apnea, only to measure it, because we had never done a proper sleep study, only a couple of nights of a recording oximeter. Is this a legitimate way of comparing treated/untreated?

   It’s been a while since we posted and would like to do an update. We’ve done two things (maybe three things; she was on her back last night!).

   Per recommendations:

      1. Turned on EPR feature fulltime; EPR = 3.
      2. Got a soft cervical collar.

Sorry for not responding for some time. Amazon was slow to deliver the collar. Below I’ve posted 3 OSCAR charts of her first night with the collar and also the first time in a long time when I found her on her back when she awoke! The first chart is of the whole night. At 3AM she awoke, the collar came unfastened, and she did not replace it. Her AHI = 2.37 for the whole 10 hours. The second chart shows only the second session with collar off and an AHI = 6.03. The third chart, when she was wearing the collar, appears to me rather uninteresting with an AHI = 0.16. The one and only event which occurred I’d even discount because she was not yet asleep. Is her flow limitation still in need of improvement by some method? Thanks for any comments.

Moabyte


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#8
RE: As Good as it Gets?
Very impressive improvement, and I think many of her CA events before were from sleep disturbance caused by the flow limitation and positional airway restriction. As a general rule, we find that flow limitation is reduced by increased EPR or pressure support (PS). You have resolved the positional apnea when the collar stays on, and the use of EPR 3 has not resulted in a CA problem. The machine is setup well for your wife and there is no more EPR to be had. I would just give it some time to see if she feels comfortable and more rested. If she feels there is a need for more PS, then a bilevel is the next step up (Aircurve 10 Vauto). These results look like they are going to settle at very good levels, so most likely an upgrade will not be supported by insurance.

As a side-note, she is using the For Her mode, and that algorithm will not increase pressure above 12 for flow limitation alone. If she was using the standard mode, the pressure would continue to rise when flow limitation is present. If you decide to try the standard Autoset mode, be sure to set a maximum pressure like 14 to avoid a runaway pressure situation.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files

How To Deal With Equipment Supplier


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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