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Help for new APAP user?
#1
Help for new APAP user?
Hi, hoping you all can provide some guidance with spouse’s treatment.

Some info that might be useful: 

Diagnosed AHI was 14. Home sleep study only. We were surprised to find so many snores reported as I felt he typically snores occasionally and mildly (although he did try to sleep on his back for the test.) Gasping awake is what prompted testing in the first place. He did remove the nasal cannula at some point during the night, and we have no idea when that happened. 

He is 35 years old and approx. 100kg. 

Since starting CPAP, best night AHI was 0.17. Worst night was 3.84. We missed data from the first week or so as we did not have an SD card. 

There have been some late-night mask removals, but usually he puts it back on. Overall average treatment time in the past 30 days has been 6:37.

Starting Rx was 4-15. He increased the pressure to 5.0, then 5.4 as he felt like he was not getting enough air at 4.0. 

He turned EPR off once (slept quite poorly, not sure if coincidental) Usual EPR 2, not sure if there’s a difference between 2 and 3. 

He tried a couple of masks. Wisp kept bumping up into the bottom of his nose in any size or adjustment, didn’t sleep with it at all. The DreamWear he currently has is the most comfortable, but sometimes leaks especially when sleeping on side. He tried the n30i hoping that the plastic nose piece would solve this, but it was not comfortable to sleep with after a couple nights trial. 

He started with the standard hose as suggested by sleep doc. He had painful nasal congestion and mouth breathing after several days. He switched to the heated hose and cranked the humidity up, and this has significantly improved. 

He feels he has had no notable changes in wakefulness, energy, etc. I have noticed some less tossing and turning and waking. 

I’ll try to attach some OSCAR charts to this post.

Now, my questions: 

Should his baseline pressure be changed? 

Is there something else we should try to improve his results, especially subjective, other than time?

I really appreciate any help with this. 


   
   
   
   
   

   
   
   
   
   
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#2
RE: Help for new APAP user?
   
   
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#3
RE: Help for new APAP user?
One minor change,
Min Pressure to 7, EPR = 3

That is a paired change,  The starting pressures will be IPAP=7, EPAP=4

The increase in EPR is to better manage the prevalent Flow Limitation, see the Flow Limitation chart and the prevalence of Flow Limitation in your close-ups.  This also pairs your pressure with EPR to give you the full benefit from the EPR from the start.

As you noted tweaking from here is mostly based on how you feel.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
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#4
RE: Help for new APAP user?
Your husband has stumbled onto most of the therapy optimization we would have suggested. He started with low pressure starting at 4.0 and felt air-starved. Increasing pressure was the right way to go. He also found pressure support as provided by EPR felt better and provided better results. The sleep test shows he had mostly hypopnea event, no obstructive apnea and a few centrals, but lots of snores. This profile is one that does better with moderate pressure and full EPR to provide pressure support (the difference between inhale and exhale pressure (IPAP/EPAP).

So now we're at 5.4 to 15 cm pressure with EPR 3 and results are looking pretty good...they can be better. In the last two charts you posted, you can see a steady low level of flow limitation. He is not fully benefitting from EPR because his pressure is still too low for EPR 3 to kick in until he reaches a pressure of 7.0. With the starting pressure at 5.4, EPAP is still just 4.0 cm. Even at 6.0 cm, it is still just 4.0. I would like to suggest he change the minimum pressure to 7.0, which will be 7.0/4.0 (IPAP/EPAP). This will make the machine more responsive and will finally give him 3-cm of EPR from start to finish. This will result in lower hypopnea, flow limitation and better breathing.

Great job on graphs! At 01:00 on June 11, you showed a close-up. We can see the inspiration is flow limited, even at 7/4 cm pressure. Flow limitation is the flat-tops on the top of those waves, and they are caused by upper airway resistance which slows the flow of air. This becomes acute at 01:01:30 and ends in a large increase in breathing flow rate and a Respiratory Event Related Arousal. On the full-night chart for 6/11 we can see that breathing is irregular from 00:20 until the CPAP raised the pressure to 7/4 and terminated the flow limitation. By starting at 7.0, we can mostly circumvent that problem and avoid the arousal.

Let's start with minimum pressure 7.0, maximum pressure 15.0 and EPR at 3 and hopefully this will feel better and be a bit of an improvement.

Edit: I see that during my verbose reply, Fred already posted the same recommendation more concisely.
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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#5
RE: Help for new APAP user?
Your great minds think alike!
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#6
RE: Help for new APAP user?
Thanks for all the help, here's today's update and question: 

I updated the machine's pressure range to 7-15 and EPR to 3. 

Unfortunately, this was probably one of the worst nights in terms of mouth leaking. Sometimes it'll just be air hissing through his mouth, other times actively trying to gasp from his mouth. Sometimes this startles him and results in changing positions, sometimes not. 

We're not sure what the next step is for that. Is there a chance this will get better with time? 

   

   
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#7
RE: Help for new APAP user?
Do either of you know whether his lower jaw drops down and pulls his mouth open when he has mouth leaks, or is it mainly just that his lips part?
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#8
RE: Help for new APAP user?
There is not enough there to worry about.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

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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#9
RE: Help for new APAP user?
Well, I saw about a dozen which, if they were mine, would probably have awakened me. Maybe after another night or two it’ll be clearer whether the leaks are disrupting his sleep.
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#10
RE: Help for new APAP user?
His jaw drops open the times that I've noticed hissing.

It does seem to be disturbing the sleep at least some of the time. He will try to breathe through mouth and gasp, toss and turn, and sometimes startle awake before closing mouth and going back to sleep.

Also, has the flow limit improved with the changes made?
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