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Intro / O2 Drops after PE; puzzling through Oscar/SP02 data
#1
Intro / O2 Drops after PE; puzzling through Oscar/SP02 data
Hello,

I am new to the board, but not new to CPAP.  I have been on CPAP therapy for many years (10+) honestly I had never really given it much thought after the original diagnosis and finding the right mask (InnoMed Aloha Nasal Pillow CPAP) and finally convincing my provider to switching me over to an auto CPAP machine about 5 years ago everything seemed fairly stable for me.. until last fall.   

Last fall I was admitted to the emergency room and subsequently the hospital for a pulmonary embolism.  Since then I have been struggling with unexplained severe O2 drops.  Cardiac issues and recurrent PE / pulmonary effusions have been ruled out.  Day time O2 drops have become manageable far less severe/frequent as time has passed, but the overnight ones continue to puzzle my pulmonologist.   They have switched me from a CPAP(Resmed S9/dreamstation) to a Bi-PAP (ResMed AirCurve 10 VAuto), and from a nasal mask to a Full Face mask.  I am currently using an AirTouch F20, after attempting several different masks (some of which actually increased my AHI... huh?).   I am on supplemental O2 at night ( I was during the day as well, before we got the day time drops under control) - and we've verified there are no "kinks" in the O2 line, that it is actually getting to the mask.  We have tried increasing the O2 from 2L to up to 5L and it seems to make no difference either.

My Doctor ordered an overnight oximetry test, but insurance doesn't consider it a priority with COVID / DME don't have a device available and supposedly it has to be by the same provider that does your oxygen.  Switching oxygen supply companies right now doesn't seem like a particularly great idea (as most of them have waitlists).  I have an oximeter on order that is compatible with OSCAR from two different places, but with COVID-19 who knows when or if it will actually show up.  I have written to both companies explaining my plight hoping for a response but so far, no luck.  I am using an alert stress oximeter (Berry Medical BM2000 watch) / wellue O2 ring, both showed to be within 1-2% from my pulmonologist's oximeter when I was in the office. Wearing both devices on opposite hands and they show consistent O2 drops/times while I sleep, so while they are not "medical devices" I am pretty darn sure the drops are actually happening (e.g. not a faulty device).  I also have woken up in pain when they happen and verified the O2 drop with a third pulse oximeter device.    

I am trying to "eyeball" align the events between the devices and what OSCAR is showing me... and I am just not seeing a corollary apnea event associated with O2 drops.   If I feel like I can't breathe / O2 drops.. something should show at least on the flow rate chart?  If there was something close, I might brave the world of beta releases to try and sync the wellue O2 ring data.. but I am just not seeing anything.

My sleep doctor says my AHI is fine (<3 most nights, and rarely over 10), and suggested meditating if I was still having issues. The pulmonologist sent me to Pain management to try and control the pain / guarding but pain management is leery of giving me anything for the pain given I am already having breathing issues.  I've been stuck in this cycle for about 3 months now, where no one seems to know what to do next.... pain / O2 drops are not going away.  With COVID still in full bloom, I am unlikely to get the formalized oximetry testing for weeks to come.

I am wondering if there is something I am missing in reviewing the Oscar logs or possibly something set wrong on the bi-pap machine? My sleep doctor basically just handed over the machine to me and when I complained it felt like he was trying to blow me up like a balloon he changed it from ST mode of 20 to Auto 4/20.   There are so many here that are good with the logs / have so much more experience that I thought I would toss out a post to see if I was possibly missing something obvious.  3 recent logs & SPO2 records attached.  Sometimes it is hard to see the trees for the forest.

Thanks,
Desiree


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#2
RE: Intro / O2 Drops after PE; puzzling through Oscar/SP02 data
Desiree, welcome to the forum. A few recommendations from your various doctors are nearly bizarre. I think they may be well-intentioned but they are not working in your favor. First, your oxygen desaturations are not related to the nasal interface you were comfortable with. Any mask that is comfortable and minimizes leaks is preferable to one that actually is more difficult to wear. A nasal pillows mask provides the pressure directly and in my opinion helps with nasal breathing which is better for oxygenation. In my opinion, the biggest problem in your charts is a high leak rate. I think if you had better control of pressure and leaks with nasal therapy, you should return to that strategy. A full face mask will not improve oxygen, and certainly not if it leaks. https://www.ncbi.nlm.nih.gov/pubmed/10629486 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466403/

You were apparently switch to a bilevel ST machine and did not tolerate the ridiculous pressure support that clearly was unwarranted. A couple of ventilation principles that any competent doctor (this usually excludes sleep specialists) should be aware of are, 1) pressure support is used for ventilation to reduce CO2, and 2) positive end expiratory pressure (PEEP) is used to improve oxygen saturation. So your sleep specialist was on completely the wrong track, and still is. On your machine, PEEP is provided by the EPAP setting, and yours starts at the default minimum of 4-cm. Your median EPAP is 8.0, and I would suggest that as a starting point to improve oxygen transfer. You can raise the minimum EPAP as high as you can comfortably tolerate, and it should yield a positive result for SpO2. The pressure support of 4.0 on your machine is fine, and it should be used mainly for comfort. You are having a number of central apnea events according to your Oscar charts, and these are generally the result of washing out CO2. You can reduce the pressure support without adversely affecting your oxygen saturation. You are increasing the amount of respired oxygen using supplemental oxygen, but it is PEEP that helps recruit lung volume and oxygen transfer. In my non-medical opinion, you would have much better therapy with a minimum EPAP pressure of 9.0, PS 3.6 and maximum pressure of 18.0. This conforms to the upper range of your needs as suggested in your charts, and the higher minimum EPAP will improve O2 transfer, while slightly lower PS may drop the CA events. You can also change the trigger sensitivity setting to "High", which will reduce some of the central apnea and might produce a more comfortable breathing sync. All this does is make the machine more sensitive to your spontaneous start of inspiration, so pressure support begins slightly earlier.
https://www.ncbi.nlm.nih.gov/books/NBK441904/ https://www.ncbi.nlm.nih.gov/books/NBK546706/

On your charts, are some clusters of obstructive apnea. You have indicated your oxygen desaturation events do not apparently align with events, but I think they do line up and it is the time-stamp that is off. You react most to the OA events. If those become a factor then the use of a soft cervical collar may help. Use the link in my signature to read about how a soft cervical collar prevents and treats obstructive apnea clusters. Your events do not look too bad, so I'm mostly just pointing that out as another option.

There are pulmonary complications in your therapy that I don't fully understand how your PAP therapy will interact. Pulmonary embolism is a medical emergency, but does not usually affect long-term CPAP therapy. Your medical team has ruled out cardiac issues. It is confounding how the oxygen bleed rate does not seem to affect the desaturation episodes.
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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#3
RE: Intro / O2 Drops after PE; puzzling through Oscar/SP02 data
Many thanks for your reply.

My Pulmonologist is puzzled as well.. 6 months out from a non-recurrent PE there should be no impact on my PAP therapy nor should there still be O2 de-stating at night / stabby pain. My sleep doctor has been largely unhelpful in this process so far.

My Bi-Pap machine had indeed skipped the "spring ahead" switch to daylight savings time but my pulse oximeters had not throwing off my "eyeball" attempts at trying to match-up events.

My sleep doctor has been a constant source of frustration for many years, sadly being on an HMO insurance plan I am severely limited by "who" I am able to see. The tech at the DME where I picked up my BiPAP machine kept insisting there were not enough numbers in the prescription to program the S mode of the Bi-Pap machine as it was written as literally "ResMed AirCurve 10 VAuto S Mode; Full Face Mask Required" with none of the other settings specified (IPAP/EPAP). Even when it was returned to program it for "auto" mode, tech again complained the new script "ResMed AirCurve 10 VAuto Auto Mode; Full Face Mask Required" did not contain enough information to program the machine. DME tech CPAPs have full auto modes, BiPAPs do not. Rather than refusing the machine a second time, I took it home at that point and have been using it for ~60 days like this. Cycling through F30 (AHI went way up > 10), dreamwear (heavy leaks), F30i (AHI went way up > 10) and now the F20 masks trying to find a full face mask that works for me. Supplier #1 has been great working with in trying to find a mask solution that works for me, as my DME only allows for "3 mask trials" with a new machine. I did briefly try the N30i mask for a week stretch (Feb 24 - Mar 2) and it seemed comparable to my old nasal mask (my DME stopped carrying the Aloha mask saying it was being discontinued though I cannot find a supporting reference to statement via google). I can post the overview charts/graphics for the entire period if it would be helpful.

Sleep doctor was also insistent there was a full face mask with an oxygen port on the mask itself (no hose / machine adapter).. which is what he wanted me to use, but I have yet to find such a mask. When I informed him of this, he stated full-face mask is still required because of BiPAP works "differently" than CPAP and pressure settings will not work with nasal pillows / nasal masks. So logically I understand if the pressure is too high and causing your pillows to pop out .. you should probably find a different mask.. but if your pressure works with your mask, why change something that works for you?

Reading the manual (oh my!) could some of my leaks might actually be caused by the O2 set at > 4L? "The AirCurve 10 device is designed to be compatible with up to 15 L/min of supplemental oxygen in S and CPAP modes and up to 4 L/min in VAuto mode. " I am using the climate line tube with the oxygen port (at the machine), not an adapter to bleed in the oxygen (although I was the first few days but the leaks were terrible thus the decision to spend $60 for the tube designed for it).

I made the adjustments suggested on my machine and will see how the next few nights go. Again many thanks for your time and suggestions <3

Desiree
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#4
RE: Intro / O2 Drops after PE; puzzling through Oscar/SP02 data
We really want to see oxygen become well-mixed before delivery to the mask, so the proper oxygen bleed adapter for your machine is actually built right into a heated tube made for this purpose. It's called the ClimateLineAir Oxy and Supplier #1 and many others carry it. Please don't mess with anything that requires a port on the mask.  Take a look at the Oxygen Bleed for CPAP article I wrote to get more important information http://www.apneaboard.com/wiki/index.php..._with_CPAP

I empathize with the HMO experience, and your sleep doctor is a quack like most of them. I think it's a specialty that must attract particularly dysfunctional individuals that don't ever meet their patients and would be dangerous doing anything else.  We can quickly recognize the exceptions that work through the real problems and advocate for their patients...you didn't get one of those. "because of BiPAP works "differently" than CPAP and pressure settings will not work with nasal pillows / nasal masks." Is complete fiction! Your choices are limited but this guy literally quacks like a duck.

My best advise is to use the mask that makes you most comfortable. Get the ClimateLineAir Oxy heated tube for your Vauto, and let's take a shot at posting some daily charts from OSCAR.  I'd like to try some Vauto settings with you rather than fixed S-mode, and see if we can't get you on-track.  It's really up to you whether you want to give some of these ideas a try, but we do at least have a fundamental understanding of how to solve problems in a sensible way.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
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Organize your OSCAR Charts
Attaching Files
Mask Primer
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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#5
RE: Intro / O2 Drops after PE; puzzling through Oscar/SP02 data
Results from last night with updated settings and on an N30i mask, overall I would say it felt largely more stable with only one large O2 crash but boy are my lungs sore this morning.  Tolerable, but sore =(  I did have some leakage on the N30i mask, which is abnormal looking back on my charts but I haven't used in a few weeks while trying to find a full face mask that worked for me so it might need some readjustment period / tightening down.

Apologies for not being clear in my earlier post about the tubing, I am using the ClimateLineAir Oxy (reference to the $60 purchase) rather than the $3 plastic bleed in part that was provided by the DME that caused large leakage.  Cervical collar from Amazon due in sometime in May, due to prioritized shipping with COVID.  It will be interesting to try when it comes in to see if it helps, but I didn't think it was critical enough to ship it urgently from someplace else.


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#6
RE: Intro / O2 Drops after PE; puzzling through Oscar/SP02 data
In Oscar you had expiratory flow limitation or snores at 08:53. I think this probably likes up with the O2 crash at 08:56. I have to run, we can talk about that later.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
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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#7
RE: Intro / O2 Drops after PE; puzzling through Oscar/SP02 data
Welcome to AB, Desiree.

FWIW I'd say you and Sleeprider are on the right track whereas that Sleep doc Duck is not, especially when he tells you (quote from your post) "he stated full-face mask is still required because of BiPAP works "differently" than CPAP and pressure settings will not work with nasal pillows / nasal masks." I think your high pressure is maybe 18. My ASV therapy could have gone as high as 26 if needed. And if I could have controlled mouth breathing/leaking better, I would have had successful therapy via the ResMed N30i nasal mask or the P30i cushions for that same frame/headgear. BiPAP works differently? It's two pressure, but otherwise it's very much the same as CPAP. Another FWIW, just say NO! to the oxy bleed at the mask. I know you and Sleeprider covered this.

My COPD has required me to research supplemental oxygen and various devices and techniques, just mentioning my background.

Just my opinion, use the mask that works for you. If it's nasal or pillows, so be it. You're the one that has to wear it. Low leak rates and comfort are high priority in my opinion.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#8
RE: Intro / O2 Drops after PE; puzzling through Oscar/SP02 data
I said I'd be back. Getting into the granular detail of your charts, we see one instance of expiratory flow limitation or snore and a generally long expiration time relative to inspiration. These features of respiration are often associated with COPD or pulmonary restriction. If you have been evaluated and that is not a problem, then that is as far as we need to go. Diagnosis of COPD is usually a simple office procedure that uses a spirometer to determine your forced expiratory volume over time to evaluate pulmonary function (pulmonary function test). If you have mild or moderate COPD or even seasonal allergies or asthma, that can explain the "sore lungs" you complained of as well as your need for supplemental oxygen. There are settings we can make to your machine to protect the expiration time and cause less stress. I am not jumping to any conclusion without your input, but the symptoms seem to add up. Let me know if you are aware of any issues like this, and we will move forward with that.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
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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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#9
RE: Intro / O2 Drops after PE; puzzling through Oscar/SP02 data
I do not have Asmtha nor seasonal allergies, as far as I know. I do run a HEPA filter in my bedroom. It reduced/stopped the congestion and headaches I was getting with PAP therapy years ago.

I do not believe I have been formally evaluated for COPD. They do the spirometer testing in the pulmonologist office every time I visit, however it is generally not well tolerated as any sort of deep breathing severely hurts my left lung. I don't have those results handy, but I do know they have not improved overly much since the initial post 30-day hospital discharge improvement.

Pulmonologist did try me on Trellegy (which I believe is a COPD medicine) for two months and it didn't seem to help with the lungs being sore so he stopped it.
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#10
RE: Intro / O2 Drops after PE; puzzling through Oscar/SP02 data
Just wanted to check on any diagnostics, and since you are under the care of a pulmonologist, you would certainly know. The changes in settings did not change inspiration or expiration time or, respiratory minute vent, and we do see an improvement in AHI with fewer OA and CA events, and SpO2 was as good to much better than the other charts, especially 4/8/20.

Your pressure was very steady last night, and while you woke up a bit sore, this looks less disruptive than previous settings where the EPAP was too low. If you want to try a little less pressure support, we can move PS to 3.0 and see if that helps with your comfort. I don't think it will increase events. I don't want to change Ti min and Ti max settings yet, but would like to know if your are at the default 0.3 and 2.0 seconds. Also, trigger and cycle are probably both set to Medium. Please verify.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

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