[Pressure] Help with dad's APAP to BPAP transition

[electric.sheep]

Hi there,

Long time lurker and sleepyhead here, summoning the optimization sages to help tune up my dad’s pap therapy. He’s moving up from an APAP to a BPAP

He’s 73, only diagnosed 7 years ago (and stoic about it), his initial PSG (2015) study showed an AHI of 54, mainly OSAs with average durations of 22 seconds, 87% average O saturation (min 78%). There was a titration test done as well, and 12.5 cm/O2 was found to be an optimal pressure rate.

He’s a twister, he goes in sleeping on the side and then he’ll spend time on his back and on his stomach.

Up until recently, to the shock of everyone, we realized we had been taken for a ride by a sleep clinic managing his pap therapy (poor fitting mask recommendations and no titration optimization despite the initial titration study’s recommended pressure).

He started his pap therapy with a Weinmann APAP (now Lowenstein) and he’s currently on an Airsense 10 APAP. Both machines had “bare” titration optimization (APAP mode, from 5-20 was “optimized” to 8-20).

From a collection of poor fitting masks (massive, massive leaks where the soup of the day, everyday), he’s been on a better fitting mask for the past month (Airfit F20 silicone).

To celebrate the demise of the sleep clinic hustler (he's definitely not in a cage in the basement...), I got him an Autocurve 10 VAuto (comes in tomorrow), and my dad and myself would really appreciate if the sages can take a look at his stats and pass on some recommendations for an initial setup, as well as advice for further optimization.

I’ve attached screenshots for the past week, which, from looking at his F20 stats, look pretty consistent (despite Wednesday’s carnage); I’m adding a summary table of his stats below, let me know if you need any other data points to be added to it.



Stat Mon Tues Wed Thu Fri Sat Sun
Pressure (med) 9 8.72 13.36 10.38 9.8 9.54 10.02
Pressure (95%) 14 15.2 20 19.98 18.7 17.8 16.12
Resp Rate (med) 14 13.4 12.6 12.4 14 15 14.8
Resp Rate (95%) 16.2 16.2 21.2 18.2 17.6 19 18.2
Insp Time (med) 1.92 1.94 2.1 2.1 1.92 1.8 1.82
Insp Time (95%) 2.62 2.5 3.2 3.06 2.68 2.36 2.64
Exp Time (med) 2.34 2.52 2.56 2.68 2.32 2.18 2.16
Exp Time (95%) 2.88 3.22 3.22 3.38 2.9 2.7 2.8
Tidal Vol (med) 440 620 660 620 460 480 500
Tidal Vol (95%) 700 780 940 900 640 660 700

*I had intended on posting all 7 days, but just noticed the attachment limitation, so I'll post 3 and will gladly e-mail or pm the rest to any sage kind enough to take a look. Hope the #$%@#$% stat table is helpful, because formating was not painless...

[Sleeprider]

It will help a great deal to get some screenshots from his Airsense 10 For Her to give you a better idea on what might have worked better on that, and to give you guidance on the vauto. The Airsense 10 could have provided bilevel pressure with a difference up to 3-cm between inhale and exhale pressure by using epr. The pressures and respiratory statistics look normal, but the inspiration time suggests a hint of flow limitation. What were the statistics on flow limit? Was EPR in use?

[electric.sheep]

That was quick, mate

I appreciate the help!

So, first post, baptized by fire, naturally. Attached the wrong OSCAR snapshots and had to delete those and upload the right ones, you probably read the post during limbo, sorry about that, mate.

You are spot on with the EPR! I forgot to mention that, and I can't seem to edit my post now... EPR is on and at 3 (that's where I'm hoping the Aircurve steps up).

Now, flow limitation stats, carnage. At 95% of events he has been between 5% and 45% (pretty much binary either between 5-11% or 30-45%), and maxing out at 100% (two nights around 60%, and the rest between 87% and 100%). He probably needs a higher base pressure, right?

Do you have any suggestions for an initial BPAP setup? (I read through the Aircurve clinician's manual, but I am definitely a rookie)

[Sleeprider]

No problem. The graphs were not there when I first commented. We see the Airsense 10 was set to 8-20 pressure with EPR 3. Events are heavily clustered and inconsistent ranging from 1.4 AHI to 14.5 AHI. This is a common pattern we associate with chin-tucking. The cause can be excessive height or firmness in pillows, or just self-inflicted acute neck angles. This is so common that we wrote a couple wikis. Positional Apnea http://www.apneaboard.com/wiki/index.php...onal_Apnea is part of the larger Optimizing Therapy article, and describes the mechanism and some self-tests for to deal with the positional clusters. The Soft Cervical Collar wiki shows how to treat the problem by preventing chin tucking. http://www.apneaboard.com/wiki/index.php...cal_Collar

I use the Vauto and consider it to be a better and more comfortable device than the Airsense 10 Autoset. Both are excellent. We can see from the charts that as long as your dad does not tuck his chin he experiences very effective consistent therapy. On Nov 30 from 23:00 to 05:00 the pressure is consistently 9.0/6.0 (IPAP/EPAP). This is a relatively low pressure. I am going to refer to his pressure in bilevel terms because that is where we are going. This result on Nov 30 shows he will do well with a minimum EPAP pressure of 6.0 and PS 4.0 (pressure support). This results in a bilevel minimum pressure of 10/6. If you can prevent the clusters of obstruction, this pressure will work all the time, however, with the Vauto, we can allow for pressure increases. Your dad often reached 20/17 pressure during episodes of positional apnea. My philosophy is that no amount of pressure will break through positional apnea, you must deal with that using a collar or ensure the conditions leading to chin-tucking are dealt with. If we don't chase these very high pressures then a maximum pressure of 18/14 should be sufficient, and will be more comfortable. This translates to settings of:
Mode: Vauto
EPAP min: 6.0
PS: 4.0
Max IPAP pressure 18.0
You can leave default values for Ti Min, Ti Max (0.2 - 2.0), trigger and cycle sensitivity (medium) and just turn off Ramp. Use SmartStart to allow the machine to turn on when he puts on the mask without having to push a button.

[electric.sheep]

Thanks for taking the time to look into this, as well as for the level of thoughtfulness (and bloody mastery) that went into your advice. Both my dad and myself appreciate it.

I did some detective work and I found that from time to time, my dad sleeps with 2 pillows stacked on top of each other, and he specifically recalls doing that the night of the multiple OSA clusters and severe flow limitation (the screenshot with the ~14 AHI night). I'd say it's highly likely that a good chunk of the other nights with similar problems will be double decker evenings, just as you very sharply pointed out.

I've actually been trying out an SCC for the past week (looks pretty promising, so far), as the result of lurking around the highly curious and discerning folk in this forum. I'll definitely share your advice on preventable positional apnea with my dad; a thinner pillow and an SCC being the cost of the comfort of lower air pressures and a reduction of unecessary apnea side-effects is by all means a bargain.

I'll try to post an update a week or so after he starts using the Aircurve. It would be great if you have a chance to share your opinion on progress/tweaking opportunities, but if that wasn't possible, no worries, I'm absolutely grateful for the generous sharing of your time and knowledge.

Enjoy your Zs, Sleeprider!

[Sleeprider]

Thanks for responding back. Looking forward to your dad's successful therapy and increased comfort that will come with avoiding the double-pillows. I'll look forward to seeing how he does with the Vauto. Other than the occasional positional issue, his therapy is actually very good on the Airsense 10. As an older guy myself. I really like a good quality real down pillow that lets my head settle to a comfortable position if I'm on my back, and can pull a corner between my lower shoulder and jaw when on my side. Might make a dandy Christmas present.

[electric.sheep]

Thanks for responding back. Looking forward to your dad's successful therapy and increased comfort that will come with avoiding the double-pillows. I'll look forward to seeing how he does with the Vauto. Other than the occasional positional issue, his therapy is actually very good on the Airsense 10. As an older guy myself. I really like a good quality real down pillow that lets my head settle to a comfortable position if I'm on my back, and can pull a corner between my lower shoulder and jaw when on my side. Might make a dandy Christmas present.

An Aircurve 10 VAuto AND a down pillow? What kind of precedent do you want me to set, Sleeprider?

Sure, the man raised me, loved me and taught me a few tricks, but let's not forget that his inheritance is sleep apnea. I love the man, don't get me wrong, but unless there's a generous trust fund or an upcoming convenient genetic trait, a bloody VAuto is all he's getting this Christmas, haha