Cervical collar results

[DanEm]

Positional Apnea (Wicki)
Only doctors and therapist think "positional" apnea means supine. We know it is really a chin tuck in any position.

Two ways to check for this Positional Apnea:
Sit relaxed in a chair and as you fully relax let your chin drop to your chest and note the increased airway resistance that may range from an increased effort to a snore or full blockage.

I did the test with no significant change in my breathing.

Another test is to gently push upward on the soft part of your jaw or neck right in front of the throat.

I also did this test with no significant change in my breathing unless I push harder.

The cervical collar's function is to prevent the chin tuck. I am pretty certain my chin does not tuck with the collar on. I have adjusted it so I am comfortable, not too tight.

The changes I can see after 4 sessions, are:

1. The duration of the sessions has increased for the 3 first ones.
   
2. My AHI has also increased for the 4 sessions.
   
3. My 95% flow limit has also increased.
   
4. For the first time, I got a Cheyne Stokes Respiration of 4,94%. Don't know a thing about that value. Is it bad, really bad or worst?
   

Should I continue using the collar?
If my chin does not tuck, as I am certain it does not, are there other factors that can influence the 95% flow limit?

I am not surprised by the mixed results. I am used to have such were my health is concerned. Diagnosis have always been hard to get and remedies often do not work when they have to come from pills.

I am eager to get your comments on this.

[Gideon]

You have 2 main issues.
1. Positional, despite your insistence your chart says it is happening.
2. Your hypopneas, Flow Limits, and RERAs are all too high. At this time I'm going to say to bite the bullet and get a ResMed AirCurve 10 VAuto as it will better treat all of these conditions with its higher Pressure Support.

Normally we eliminate the Positional first, then tackle the rest.

There is no way that a VAuto will hurt you, outside of possibly the pocketbook, it is in general a better and more capable machine than your AS11.

[staceyburke]

On your left hand column it shows EPR is set for ramp only - It should be set to full time.  IF it is correct that it is only on ramp you are NOT getting any benefit of EPR and your flow limits are off the chart.

[Gideon]

I missed the Ramp Only for EPR.

Set EPR to Fulltime and keep EPR=3
That should significantly reduce your events.

[Deborah K.]

I am not one of the experts, but it looks as though you are limiting your upper pressure to 16. I think you should raise that to 20, as you are topping out regularly. If I am wrong, one of the experts will chime in.

[Gideon]

in this case the pressure will always go to the upper limit driven by the events.
When we see some conttrol of these event we may, or may not increase the upper limit. just not now.

[DanEm]

OK, take a look at the screenshot of my graph.

From #2 to #6 the AS 11 was set to EPR: Full Time - 3. That was a one month period.

Unless I am missing something there was no significant change to my 95% flow limit.
And no significant change to my positional apnea.

The last four session in red are with the cervical collar.
There also I do not see a significant decrease of my 95% flow limit but rather an increase.

I did change to  EPR: Ramp Only - 3 at the end to see if there would be any change.  My conclusion is that at those settings, nothing changes for me. Am I out in the woods with the proverbial bear?

I hope I am wrong somewhere and I hope you understand my concern and questioning.

B.T.W. from Jan 18 to Jan 22 my max pressure was 18.  It was then reduced following discussions here.

I will consider the ResMed AirCurve 10 VAuto.  It is a big step. My AS 11 was covered by my insurance (80%).  Getting a new machine before a 5 year period wait I would bare 100% of the cost.  I briefly looked at the prices and they were close to $3K.  
I need to feel confident it would be my best shot at improving my sleep.

Still begging you to squeeze your brains on my case.

[Sleeprider]

DanEm, your FL has trended higher with the SCC. We don't know much about what collar you are using, dimensions, how it fits or what it is about its use that has made your sleep and therapy worse, but at face value, it is doing more harm than good. Your trend for 95% flow limitation has been consistently around 0.3 with large spikes above that on nights with high AHI and a number of nights at 0.15 to 0.25. None of it meets our usual goals for 95% flow limit less than 0.1 and AHI less than 5.

The solution is either going to a significantly higher pressure support by a bilevel device, or working with an ENT or other specialist to identify the physiological source of obstruction and airway resistance. I think you have exhausted the capability of the CPAP to provide consistently better therapy, and for that matter, our ability to coach you in optimizing CPAP and using sleep position and a soft cervical collar as a supplement to CPAP therapy. You occasionally have very good therapy, but it is more frequently disrupted with episodes of much stronger obstruction. What we have learned is that you do best with consistently higher pressure of 16-17 cm. Your CPAP is only capable of delivering 20 cm, so at your current pressures, you would qualify for bilevel in the U.S. I have no idea whether you can persuade a care provider in Canada to move to bilevel, but it is the obvious next conventional therapy step. Gideon has personal experience with these high pressures and bilevel therapy, although he is using lower pressure today.

To my eye, you need to move to bilevel, and attempt titrations perhaps up to 24/20 (IPAP/EPAP). You might want to try using your CPAP at 20/17 pressure and see if that holds the events at a reasonable level. Basically we are talking a minimum pressure of 16, maximum 20, with EPR 3. If you need ramp for comfort adjustment, use the auto setting and a minimum pressure high enough for comfort. The collar is not working and you can shelve it.

[DanEm]

Thank you Sleeprider.

I appreciate your comments and will try first testing the higher pressure.

I will comme back to the forum with a few days of data.

If it does not work, I will have to better investigate how I could get a bilevel device.
If I go that way, I will most probably ask for your guidance.

Thanks to all for your patience with me.

[DanEm]

Sleeprider
You might want to try using your CPAP at 20/17 pressure and see if that holds the events at a reasonable level.

I did just that. One exception, I mistakenly set the low pressure to 16 instead of 17.
I will reset it to the 17 for my next sessions.

The results for my last 5 sessions are shown in the screenshots.

Looking at the Flow Limit graphs, there was a change from previous ones.
I think it is positive.
One thing that bothers me, is the sudden jump for the third session on Sat Feb 5 and for the first session on Sat Feb 6.
Nothing was changed for those and I did not feel any different.

So here are my questions:

Is this enough information for you to confirm that I definitely should change for a bilevel machine or should you/I wait after further testing with the proper pressure levels?

Have you any comment on the sudden increase of the Flow Limit? Is it something that you see in other sleepers?