Help with optimizing PAP for 85-year-old

[Sleeprider]

Unfortunately, we only have a summary and no idea what results were for other pressures or if the reduction of events was linear, or even what kind of events were recorded. Request the detailed results. I'm certain that this was simply a typical window where CA events were less. Also, what were the SpO2 results. If your doctor or clinic can only quack and not tell your logically their strategy, you know they are quacks. This looks like quacks and you need to move on to a competent professional.

[QuestionableQuerant]

Thanks, Sleeprider. Yeah, I'm going doctor shopping for my dad.

But, I don't get it. His current practitioner is both highly experienced and unusually well-credentialed, with diverse intellectual interests - certainly no quack, at least not as I understand the attributes and qualities typically ascribed to quacks.

All I can think is that this doctor may be badly overextended due to his position and attendant responsibilities. Or, more darkly...there are some right powerful disincentives (professional, financial, or administrative) dissuading him from prescribing ASV for my father. Even so, ASV aside, if he could've offered at least *some* semblance of a strategy for improving his sleep...

Oh well. In any event, barring a pleasant surprise from the doc - time to move on.

[QuestionableQuerant]

(Second update)

Late September, I took my dad to see another sleep doc (pulmonologist) for a 2nd opinion. While it took a bit of convincing, he ultimately proved sympathetic and prescribed an ASV - and even arranged for a rental, with the possibility that Medicare could ultimately cover the cost in the future should the results justify.

On the odd chance it might prove helpful to someone who finds him/herself needing to make a case for one therapy or another under similar circumstances, I've attached a synopsis of my father's history w/PAP that I presented to the doc at the start of the appointment.

After I spend a bit of time trying to familiarize myself with the finer points of ASV/ASVAuto, I may need once again to solicit the feedback and help of the gurus w/r/t optimizing settings, minimizing mask leaks, etc. (he's been off to a bit of a rough start w/ASV) - but would start a new thread for that.

Thanks, all, for your help to date...

[QuestionableQuerant]

(Second update)

Late September, I took my dad to see another sleep doc (pulmonologist) for a 2nd opinion. While it took a bit of convincing, he ultimately proved sympathetic and prescribed an ASV - and even arranged for a rental, with the possibility that Medicare could ultimately cover the cost in the future should the results justify.

On the odd chance it might prove helpful to someone who finds him/herself needing to make a case for one therapy or another under similar circumstances, I've attached a synopsis of my father's history w/PAP that I presented to the doc at the start of the appointment.

After I spend a bit of time trying to familiarize myself with the finer points of ASV/ASVAuto, I may need once again to solicit the feedback and help of the gurus w/r/t optimizing settings, minimizing mask leaks, etc. (he's been off to a bit of a rough start w/ASV) - but would start a new thread for that.

Thanks, all, for your help to date...

2nd try on adding the attachment (initial attempt failed due to user error/obtuseness)...

[Sleeprider]

Let us know how the ASV works out. I would expect considerably fewer events and better profusion.

[QuestionableQuerant]

Thanks, Sleeprider.

Dad's persevered through six nights to date of using an ASV and, after some initial leak management hiccups (discussed w/in another thread) and challenges with acclimating to the occasional sudden increases in pressure, he's beginning to adapt and become more comfortable. After nearly three years of using xPAP therapy, he enjoyed his best ever AHI (2.95) last night (attachment: ASV - night 6.png). More important, he seemed just a bit more himself today.

However, the considerable improvement notwithstanding, I'm wondering if I could pose a few additional questions for when you have time, particularly in relation to whether the results suggest that additional (minor) adjustments might be worth considering (if this requires its own thread pls let me know and I'll create):

He continues to experience the odd hypopnea cluster, as was true last night (attachment: hypopnea cluster early in sleep.png).
* The machine's been responding to the hypopneas by maxing out PS while maintaining a steady EPAP (does this suggest that the hypopneas in question are more likely central than obstructive in origin?).
* I boosted the max PS setting today by a tick (from 12 to 13).

• Was that an appropriate response?
  
• If so, should I continue until the hypopneas become less frequent?
  

While the flow limitations are fewer and farther between than they ever had been w/APAP or CPAP, he still has the odd occurrence or cluster of occurrences (attachment: flow limitations following hypopnea cluster.png).
* Unlike with the hypopnea clusters, the machine doesn't seem to have a consistent response to the flow limitations.
* When zooming into the flow rate table for these events, I didn't find anything that seemed obvious to my untrained eyes (perhaps some blunted inhalation?) - yet the pressure support isn't typically jacked sky high during these episodes, either.
* From the data and graphs, do these FLs seem pretty typical of what might be expected for someone on ASV therapy or do you think they might merit further attention (increased min EPAP, perhaps)?

While EPAP is set to 4 - 11, its average nightly value to date is ~6.4.
* Last night, average EPAP was a little under 4.7, its 95% value was ~5.7, and it maxed out at ~6.6.
* Do I need to boost EPAP's min value or am I safe in assuming that the machine would do so automatically if the need presented itself?
* Also, can we infer anything re: the nature of his sleep breathing issues from the rather low(ish) EPAP values (e.g., perhaps obstructive issues aren't quite as primary as thought)?

Thank you again for all your help - apologies for the length.

[Sleeprider]

You're on the right track with settings, but as you said "clusters of hypopnea" suggest obstruction. They are not UA, so apnea are not happening. Be aware that chin-tucking is the leading cause of of airway restriction or resistance. Respiratory effort becomes more difficult when the airway is restricted in this way, so avoid excess pillows and sleeping positions that tilt the head forward. This applies whether he sleeps on his back or his side. We see the same restriction from people that sleep tucked into a fetal position. don't think you need to consider a soft cervical collar, but read this as a possible theory on why apnea or hypopnea clusters happen http://www.apneaboard.com/wiki/index.php...onal_Apnea

[QuestionableQuerant]

Thanks again - from what you've seen do you think I should consider boosting his min EPAP (from 4) or leave that alone for now?

[Sleeprider]

The titration protocol calls for increasing EPAP when obstructive apnea or hypopnea are present.  I think that is the case here, and increasing by 1-cm is a reasonable response.  This won't improve the event rate if obstruction is positional.

[QuestionableQuerant]

Thanks, Sleeprider. When you have time, I was wondering if I could again trouble you with a few additional questions.

Last night (screenshots A and B), my father enjoyed what (I think) was a rather good session, overall. However, while his sleep with ASV is much improved over what it had been on APAP, I'd nonetheless like to reduce, if not eliminate outright, the periodic hypopnea clusters apparent since he first started with ASV therapy.

In search of a pattern, I looked through some of his recent sleep data from when he used ResMed's APAP, concentrating particularly on those nights when leaks were minimal and, thus, unlikely to be a confounding factor. While doing so, I noticed that his event while using APAP were more common than I'd remembered. I noticed further that his APAP machine frequently - though not exclusively - categorized those clusters as clear airway events (screenshot C).

In addition, a fair number of those clusters were also flagged as suspected CSR episodes. Possibly of note: 1) as happened for a time during last night's hypopnea cluster, my father will every so often sleep noisily for brief periods (guttural vocalizations with some bodily movement) and 2) his recent polysomnogram confirmed that he experiences occasional periodic limb movements during sleep. Further, I saw no evidence of chin tucking during the time when last night's hypopnea cluster occurred (I happened to walk in on him and saw that he was supine with his head leaning back on the pillow and the neck well-extended). I, too, wondered whether some of this stuff might be positional, but both a home sleep study a few years back and the recent polysomnogram found that his apneas occur in all positions. Full disclosure: a couple of months ago (before seriously entertaining switching from APAP to ASV), I suggested that he try using a soft cervical collar for a night or two, just as a test; the suggestion was less than well-received.

From what I've written together with the screenshots, do you think the hypopnea clusters reported by his ASV might be analogs to the event clusters reported by his former APAP machines? If so, do you think it's possible that the ASV-reported hypopnea clusters could be more central than obstructive in origin, as the usual initial response of the ASV to their appearance is to max out pressure support rather than raise EPAP?

Last night, I tested the effect of increasing min PS from 3 to 4. While doing so might have helped just a bit, given last night's data (screenshots A and B), I'm now wondering whether it would be better to restore min PS to its former value (3) and increase max PS from 14 to 15.

A couple of nights ago, I tested the results of boosting min EPAP (from 4 to 6). While hypopneas were still present (2.89 HI, 4.15 AHI), the clusters were smaller and more evenly distributed throughout the night. However, intermittent small(ish) leaks may have been a confounding factor (over the leak redline ~3.5% of the time that night).

So, after all that, I'm wondering if his best settings - at least for now - might be EPAP: 4/12; PS: 3/15. Is there anything in what I described or the attached screenshots that might suggest otherwise?

Thanks again for your help and patience. I just want to optimize his sleep therapy (minimizing both events and arousals) to the greatest extent reasonably possible - and I think that's already far closer now than I could've hoped even just a few short weeks ago.