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Jadazu treatment thread
#11
RE: Jadazu treatment thread
Seeing your last statement, I suspect you are referring to a Nasal Pillow type of mask. Did you set your CPAP from the FFM, listed in your profile, to a Nasal Pillow?
Crimson Nape
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#12
RE: Jadazu treatment thread
I am curious have you tried the nasal mask without the cervical collar? One or both could be the reason for improvement.

The periodic breathing does look central in nature, this is something that may improve with time. If it doesn't you could try reducing EPR to 2 to see if that helps but the higher EPR is good for the periods of restricted airways/flow limitation so it is a bit of a trade off and may or may not improve sleep quality even if it gets rid of this periodic breathing.

Oh and the bed at sleep study sucks, mine have been nice comfy beds so must depend where you have it done. If you get poor quality results you could try complaining. I had some complaints after my first study and got a second one half price because of it.
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#13
RE: Jadazu treatment thread
Crimson Nape,

Yes, I did set the machine for the Nasal pillows mask type. I didn't update my profile... I'll do so now. Thanks for noticing that!

Geer1,

I think the collar is the primary reason that my therapy has improved. I'll add a screen capture from five days ago. That evening I started sleeping without the collar on, I had left it in my travel bag, and I'm not yet habituated to putting it on. (I was tired, and I forgot about it....) I was using the nasal canula mask, and had been using it for the preceding 10 or so days.

   

   

At about 1:15, I woke up in feeling bad, with a headache and the air pressure high. I ate some advil, drank some water, and got the collar and put it on, and went back to sleep. The difference between the first half of the night and the second half isn't just my wearing the collar, but I think it is most of the improvement. I didn't do anything else to reduce my mouth air leakage.

I did write a polite complaint to the hospital about the bed. The rest of the test was okay. In all of the PSG's i've done, there was always something stupid that was wrong, at least one 'fly in the ointment'. That is something I just cannot understand...

I will try reducing the EPR to 2 for a while. I have a couple of weeks of records of sleeping with these current settings.

Just for fun: I remember when, in the fire service, we would have to sit thru some kind of required recurrent training, and if we were tired from working a call, we would put on a no-neck adjustable hard cervical collar under our shirts or jackets, and sit in the back row of seats. We could nap or sleep without having our heads nod or bob...

Thank you,
Jim

ETA: I should clarify that I've tried several soft collars, and the one that I think is effective is tall enough to fit 'tight' under my chin, uncomfortably so, until I got used to it. The shorter, 'comfortable', collars did not seem to be very effective.

ETA: I don't have any CPAP machine data from my prior years of therapy, but I do have pulse-oximetery data. The consistent frequency SpO2 fluctuations have been a constant feature in that data over the last 15 years. They've occurred about one third to one quarter of my sleeping time.
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#14
RE: Jadazu treatment thread
Yeah that seems to support that the collar is the difference.

Instead of trying reduced EPR I would try increasing min PS to 10 since there seems to be an obvious obstructive issue. The combination of collar and higher pressure may help maintain airway better.
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#15
RE: Jadazu treatment thread
Well, now I am in need of some help.

I had a PSG just over two weeks ago, and I had the follow-up consultation a couple of days ago. I'll cut-and-paste the synopsis of the test results. (I apologize for the length and the routine 'boiler-plate' stuff...)

"___ ______ , M.D. 6/15/2021 4:43 PM
Technical summary: The patient underwent a CPAP titration. This
was a 16 channel montage study to include a 6 channel EEG, a 2
channel EOG, and chin EMG, left and right leg EMG, a snore
channel, and a CFLOW pressure transducer. Respiratory effort
was assessed with the use of a thoracic and abdominal monitor and
overnight oximetry was obtained. Audio and video recordings were
reviewed. This was a fully attended study and sleep stage scoring
was performed. The test was technically adequate.

"Interpretation:
Study start time was 09:38:39 PM. Diagnostic recording time was
8h 37.0m with a total sleep time of 5h 30.5m resulting in a sleep
efficiency of 63.93%%.
Sleep latency from the start of the study was 12 minutes and the
latency from sleep to REM was 79 minutes.
In total,86 arousals were scored for an arousal index of 15.6.

"Respiratory:
There were a total of 1 apneas consisting of 1 obstructive
apneas, 0 mixed apneas, and 0 central apneas. A total of 36
hypopneas were scored.
The apnea index was 0.18 per hour and the hypopnea index was 6.54
per hour resulting in an overall AHI of 6.72.
AHI during rem was 23.1 and AHI while supine was 0.00.

"Oximetry:
There was a mean oxygen saturation of 93.0% with a minimum oxygen
saturation of 86.0%. Time spent with oxygen saturations below 89%
was 1.9 minutes.

"Cardiac:
The highest heart rate seen while awake was 86 BPM while the
highest heart rate during sleep was 79 BPM with an average
sleeping heart rate of 66 BPM.

"Limb Movements:
There were a total of 0 PLMs during sleep, of which 0 were PLMS
arousals. This resulted in a PLMS index of 0.0 and a PLMS arousal
index of 0.0.

"CPAP was tried from 6 to 13cm H2O.

"CPAP Titration: The PAP titration was initiated with CPAP 6 cm
of water and the pressure which was slowly titrated up in an
attempt to eliminate sleep disordered breathing and snoring. The
final pressure tested during the study was CPAP 13 cm water and
at this final pressure the patient was not observed in the supine
or REM sleep stage. The apnea hypopnea index improved to 1.6 per
hour and O2 nadir 90%. He spent 0.3 % of sleep time below 89% O2
saturation. Snoring was resolved. The patient utilized medium
N30i mask with heated humidification. The CPAP was well-tolerated
and there were minimal air leaks. No supplemental oxygen was
required.

"Impression:
1. Obstructive sleep apnea

"Recommendations:
I recommend CPAP 13 cm with N30i mask. Recommended 30 day
compliance download to assess the efficacy of the recommended
pressure and compliance for further outpatient monitoring and
management of CPAP therapy. In some cases alternative treatment
options may prove effective in resolving sleep apnea and these
options include upper airway surgery, the use of a dental
orthotic or weight loss and positional therapy. Clinical
correlation is required. In general patients with sleep apnea are
advised to avoid alcohol and sedatives and to not operate a motor
vehicle while drowsy and are at a greater risk for cardiovascular
disease."

My point of view is that is was another not-very-good test. I slept little, less than the reported 5hrs 30min.

The sleep doctor who ordered this test and consulted with me in the follow-up appointment, is new to me and I have only been in his care for about three months. So far, I am favorably impressed by this new-to-me physician. I told him the my sleep during the lab PSG was very non-representative, and the he understood.

His suggestion for treatment is CPAP at a pressure of 11cm and EPR that is comfortable, and use of a full face mask.

I have slept two nights using that prescription. I'll post the two nights' reports below.

   

   

Wed night's sleep stated with a significant de-saturation.

   

The wave form of the hypoxic period looks to me like impaired breathing, and the flow limitations were high. Below is a detail of the transition to more normal breathing. (OK, i'll attach it in the next post...)
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#16
RE: Jadazu treatment thread
Ok...

Here is a detail of the transition between the flow limited breathing and the non-flow-limited breathing.

   

The flow limited breathing looked like this.

   

The inspiratory flow was restricted, I think, significantly.

   

I am wearing a Coreflex cervical collar, and that has, more or less, eliminated the obstructive apneas that I was having. The de-saturation was correlated on several channels of the data. I don't think that it is anomalous recording or data. The oximeter is a Nonin clinical probe attached to a ResMed oximetery expansion module, recorded on the machine data card.

Please tell me if you have any observations or ideas of what this might be caused by. (Over many years, I have recorded many similar de-saturations on oximetery data.)
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#17
RE: Jadazu treatment thread
How many minutes total was the SpO2 below 89%? If your total was 6 or more, you need to discuss this with doc. If less than that, keep a watch on the oxygen level.
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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#18
RE: Jadazu treatment thread
This data shows obvious restriction.

The question is whether higher pressure will help stint airway open further and avoid his restriction, whether positional apnea is still having some effect at times or if higher pressure support with a bilevel will be required to overcome restrictions. 

The tech saw this during titration and raised pressure to try and treat it. None of your data posted indicates the pressure support levels he used so I am assuming straight pressure which would mean his titrated pressure was 13 cm EPAP which is noticeably higher than your current EPAP of 8 cm (11-3 EPR). Since there isn't much more that can be done regarding positional apnea or restrictions I would try higher pressures to see if that seems to help. 

You can do this by raising pressure, reducing EPR or a combination of the two depending on what feels most comfortable.
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#19
RE: Jadazu treatment thread
Dave,

These kinds of hypoxias are 'regular irregular' events, for me. Not regular enough for the doctors I have seen to do anything about it. I've sent screen captures in a note to the new doc, I'm hoping he will be concerned.

Geer,

The screen captures are from my sleeping last night, using the doctor's new prescription of 11cm CPAP and 3cm EPR.  This may have been positional, I don't know. Presently, I told the doctor I would agree to use the new prescription for 30 days and review it after that. I'm going to continue with it unless/until a significant de-sat happens again. (I feel like I should use APAP, from 11cm up to 16 or 18cm. The doc thinks that straight CPAP is better, that not having pressure changes is less disruptive to my sleep.)

Ive purchased a webcam, to try to figure out what is happening...
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#20
RE: Jadazu treatment thread
Sometimes the static single pressure can help. If it feels or looks less effective than go with your APAP range. Mostly doctor like static pressure because you're supposed to rely on him to adjust pressures accompanying a visit with boat payments.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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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