RE: In anticipation of my BIPAP Re: New Thread

[ApneaQuestions]

Hi Phoebe,
I have a question for you.. I've lost track of the mask-types that you have tried.
Have you ever used a mask that is entirely nasal ie that does not provide any air supply to the mouth?

[Plmnb]

Hi AQ.  Tried them back around 2003.  From day one they would be on the floor in the am.  Probably due to the fact that I always breathe through my mouth.

Plmnb

[Plmnb]

Thanks ntn.

Will look into this after neurology doc.

Regards,
Plmnb

[ApneaQuestions]

I often find myself wondering what could be causing your flow limitations.
The videos haven't shown anything obvious so what can it be?

For a totally unrelated reason I was looking at various websites including patent applications.
I stumbled into this throw-away sentence on a ResMed patent application. (bold font is my emphasis).

Nasal Continuous Positive Airway Pressure (CPAP) therapy has been used to treat Obstructive Sleep Apnea (OSA). The hypothesis is that continuous positive airway pressure acts as a pneumatic splint and may prevent upper airway occlusion by pushing the soft palate and tongue forward and away from the posterior oropharyngeal wall.

This got me wondering, could positive pressure coming into the mouth have the opposite effect and push the tongue and soft palate backwards towards the posterior wall?
Then I also thought about your Uvulectomy and wondered if that too might allow the tongue etc to move backwards and cause an obstruction.
If we then add in your small mouth and large tongue... well you can see where I'm heading.

So if I turn this into a hypothesis... Could positive mouth pressure actually be contributing to (or maybe even causing) some of the car-compactor flow limitations?
This might explain why your flow limitations are sometimes "OK" but then switch over to "awful" for (apparently) no discernible reason.
Could it be that your tongue sometimes gets pushed backwards by the incoming mouth pressure and the blockage then occurs?

Although you had no luck with a nasal mask back in 2003, I wonder if it might be worth trying a nasal mask to test the hypothesis?
I can't remember why the nasal mask failed in 2003. Was it "simply" that you kept taking it off or was it because your nose is still congested even after surgeries and you cannot get enough air through your nose?

Just a thought.  Easy to test.

[Geer1]

I wondered about that earlier as well. My grandfather cannot get a full face mask to work and this could be a similar situation. He can get most obstructive apneas controlled at 10 cm with nasal mask but can't control them with 20 cm on full face mask. In his case it has to be related to pressure distribution pushing back/down on either palate or tongue.

[Plmnb]

 Hi AQ, Sleeprider, Geer1, and all,

Thank you for continuing to try to help me.  You guys are spending a lot of time wondering about my situation, hope your own apnea battles are going well.

Interesting information, appreciate it and will ask the doctor.  

My very best friend of over 40 years was in town yesterday.  She was a respiratory therapist before her retirement.  I hadn't mentioned this latest go around with SA, frankly I forgot to bring it up...until yesterday.  Here is her take on things:

As per the ENT I have very narrow nasal passages, Class III tongue.  My friend said this is causing me to not get enough air, with PAP or no PAP.  My body is trying to protect itself and get more oxygen.  This is why I sit up.  She said the body just naturally breathes better in a sitting position.  Because I am sitting cross legged and also leaning on my leg I have developed the Meralagia. (I REALLY need to get the O2 device up and running I guess, but if I don't, her explanation makes perfect sense).

I am getting my documents and records in order to take to the neurologist/sleep doctor on the 4th.  While going over my sleep studies I located the O2 portion of the reports from November and December.  My November Baseline study shows the following:

AVERAGE O2 while in REM 88%
AVERAGE O2 while in non-REM 92%
MINIMUM O2 saturation asleep 75%

I can't remember if I had a CPAP Titration

My December Titration for the BIPAP:

AVERAGE O2 while in REM 97%
AVERAGE O2 while in non-REM 96%
AVERAGE O2 saturation asleep 87% 

(I had NO Titration for the ST-A)

Below is the OXIMETRY data from the December sleep study.  I looked up the % for which a person's O2 should not go below while asleep and from what I found I am only a few percentage point below what they should be while sleeping.  But I also found that if this happens too many times this could be an issue too.

Is there a way to tell from the below image how OFTEN or how many TIMES my oxygen was too low while using a PAP?  Since I am having the same sleep issues on the ST-A I am starting to think getting enough oxygen is my main problem.  Since I take the mask off so often these days I am literally starving for oxygen for much of my sleep time (SEE ABOVE, FIRST OXYGEN RESULTS).  With the mask on, I just seem to barely get enough.


[attachment=20426]

Thanks,
Plmnb

[mper6794]

Plmnb,
I have been following with empathy your journey from a distance.
Taking into account your posted long history as a smoker, high blood pressure, your graphs and responses to pressures, etc,
one thing has been intrigue me; it might be worth asking: have recent clinical medical exams and tests definitively rule out COPD in your case?
Apologies if you have already answer this elsewhere.

All the best
Mper

[ApneaQuestions]

It sounds like your friend is seconding my hypothesis on the Yoga stuff.  Of course, we could both be wrong.  It's just my best KISS hypothesis.

The sleep study should have been measuring the SpO2 levels throughout the night and therefore giving you histograms and graphs describing how low the SpO2 was, how long it stayed low, when it came back up, when it went down again etc etc.  That summary you posted is not very informative and seems to be part of a dumbed-down report.

The O2 information was there on the PSG system and it's a bit shocking if they didn't provide more details to you and the doctor.  If you give them a call they might be able to pull up your data, push a different report button and give you the more detailed data that you want and (IMO) paid for.

EDIT: To get a feel for the immense amount of data that the PSG systems record, look at a thread I created recently.  I got the full PSG dataset from my sleep study partly because I wanted to do my own analysis and partly just for academic interest.
http://www.apneaboard.com/forums/Thread-...DF-Formats

EDIT2: Having said all that... a minimum SpO2 of 87% is not a cause for alarm if it stayed in the 90s most of the time and only dipped down there briefly. That's what the histograms and detailed statistics would tell you if you had them.

[Plmnb]

mp6794...Thank you very much for following my journey!  COPD as it realtes to my situation has never been mentioned.  Of course they ask about my smoking history but when they do the breathing tests in the little booths and x-ray, and whatever the other test is to look at my lungs is, always come back in good shape.

My husband does have COPD and his symptoms are very apparent.  So I'm thinking I'm ok in this regard.  (Although strenuous exercise, lol and chores like mowing the grass cause me to have to breathe pretty hard).

AQ, I'm calling my sleep drs. now for the data you say I should have!

Regards,
Plmnb

[Geer1]

I doubt COPD, the flow limitations are real and plentiful. If you had COPD and this level of flow limitation I would think your O2 levels would be a more obvious issue.

The issue is clear at least in my opinion, nearly unstoppable flow limitations. The strange thing about them is how unresponsive they are to PAP treatment.

Flow limitations can cause two problems. Oxygen desats or arousal due to CO2 levels. UARS as you see commonly posted about on here usually has more of an issue with arousals rather than desats. This is what I believe your issue is as the arousals are present and they cause significant issue that lead to problems with compliance (mask removal etc) and as your friend said likely your yoga poses etc.

Imo the only way you will find successful treatment is by figuring out ways to stop or significantly reduce these flow limitations. As I mentioned before increasing EPAP is probably the only remaining option in terms of PAP treatment and is not guaranteed to work. Narrow airways isn't a good enough explanation in your case, you need a good ENT, sleep doctor etc to pinpoint the cause of these flow limitations somehow and do something to minimize them. ENTs might have to consider other surgeries, maybe something like the inspire implant etc but all this requires them to pinpoint the primary restriction causing these nearly untreatable flow limitations. Maybe an ENT can do some sort of overnight scope test to visually see the restrictions in action, I'm not sure what all is available in that regard. I just know most doctors will probably have minimal experience with this and might be of minimal help because of it.