help setting my 91 yo dad's bipap machine

[katez]

I would appreciate any tweaking suggestions to help my dad with his "new" Resmed Aircurve 10 vauto machine.  The doctor's office feels the provider should do a home visit for a mask fitting with the new machine.  The provider does not offer that service.  He has received many masks from the provider to try at home.  The Amara View with a chin strap going from his mask to the back of his neck decreased leakage 2 weeks ago to near 0 and his AHI was between 10 and 20.  Then it started leaking and we put on a new cushion which was great until 3 days ago, now we can't get it to stop leaking again.

The provider set him up with the "S" mode on the Aircurve 10 with an initial inhale pressure of 25.  My dad could not tolerate it that high.  I have been playing with lowering it and last night I switched the mode to "VAUTO".  I do not know why they chose the "S" mode over VAUTO.

He has COPD and is on 3 liters of oxygen during the day.  He mouth breathes while sleeping so trying to fit him in the store doesn't show that he has a leakage problem.

   
   
   

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Here is the 4th screen shot of his data.

   

[Sleeprider]

There is a significant problem here, and without looking at a closeup of the respiratory flow (about a 3 minute zoom) it's hard to know what is going on. Your dad really needs a titration study that evaluates ASV or iVAPS backup rates to see what might help. I'm conserned he is being treated with a bilevel without backup rate, but needs a respiratory assist device with backup rate. The only way to get that done is to get back to his sleep doc and ask for a titration with bilevel with backup rate. He has a great machine, but it's not working for his issues. You should get a pulse oximeter on dad. He is in danger with these results and needs professional attention we cannot provide on the forum.

[katez]

Thank you for your reply.
My dad is in bad shape.
I have set the machine back to the S Mode with an ipap of 18 and epap of 14 which is where the respiratory therapist lowered it after I told them that 25 was too much for him. He was refusing to wear it because it was blowing so much.
He had a sleep study in May where they said he did best at a pressure of 25 for ipap and 19 for epap.
It took 3 months for the bipap machine to arrive after the sleep study.

Can you tell me if the cpap mode on the Aircurve 10 vauto is equivalent to the Airsense 11 machine?  I have not turned in the Airsense 11 because he sleeps better with it and I don't want to lose it as a backup if we can't get the Aircurve to a setting that doesn't make my dad want to throw it out the window. But Medicare is starting to complain because he has both machines...

[Sleeprider]

Airsense 10 and 11 CPAP modes should be identical with the same EPR. Do you have any data from the CPAP?

I have no problems trying to help you optimize the settings on the Vauto. There is a lot that has not been touched, but we really need to start with a zoomed view of the respiration flow rate wave to help. Your dad averages very short inspiration time which is consistent with the low flow limitation index. I just think he needs a ventilator that paces his breathing. It's awful that the sleep "industry" treats everything as obstructive sleep apnea. I don't think that is what we're looking at in this case. It would help if he didn't have such a high leak rate. That's a huge interference to seeing the flows.

[katez]

Is this what you requested?  

I do have screen shots from a good day using his cpap from before he received the bipap, after he received the F20 mask with memory foam that stopped the leaks for awhile.

When the leak numbers are down, he is having more clear airway apnea. When leaks are high, I assume OSCAR has difficulty determining the specific types of apnea.

We have not found a mask that works when he goes into a deep sleep and his mouth drops open, below his mask.

   

   

   

I really appreciate your input.  There are a lot of factors and I don't think we have the time for me to dive much deeper.  I just wish we had more support from the provider.

[Sleeprider]

The results clearly show inspiration time increases while tidal volume decreaes. This very strongly suggests upper airway resistance and obstruction rather than central apnea. The mechanism for this would be chin-tucking with increasing airway resistance as the chin drops. As breathing effort increases the time of inspiration increases as it becomes harder to suck air past the obstruction in the upper airway. This leads into full obstruction or apnea, then arousal with recovery-breathing and hyperventilation. This cycle repeats many times. An interesting feature of your dad's apnea is a large leak during each apnea. This would be caused by the chin-tucking dislodging the mask and causing a leak, which clears up on arousal and recovery breathing. You need to carefully observe and consider his sleep position and whether it promotes obstruction of his airway by chin-tucking. Extra pillows or just his sleep position can promote this due to loss of tone at the age of 91. A possible solution may be a soft cervical collar to prevent the positional apnea. We have several wikis that deal with this.
Positional Apnea describes the mechanism: http://www.apneaboard.com/wiki/index.php...onal_Apnea
Soft Cervical Collar specifically addresses the use of a cervical collar to prevent the apnea:http://www.apneaboard.com/wiki/index.php?title=Soft_Cervical_Collar

Assuming this is obstructive, you should increase the minimum EPAP pressure from 4.0 to 9.0. I would also like to see more pressure support for his COPD, but we need to stabilize the obstructive apnea in order to evaluate the respiratory volume and PS needed to assist that. You can also increase the trigger sensitivity to high so that it takes less airflow or effort to trigger IPAP. There is nothing to suggest that either higher pressure or more sensitive trigger will resolve this without positional therapy in the form of a soft cervical collar. This will also stabilize his sleep position and reduce mask leaks.

We can't fully eliminate the possibility that these apnea are central in nature, and if a soft collar or similar approach does not resolve this, you will need to talk to your doctor about getting a titration on an Adaptive Servo Ventilator (ASV) or at least having his sleep observed. The Aircurve 10 Vauto is incapable of treating central apnea, but the Aircurve 10 ASV most certainly is. If you can observe his sleep, I think the problem should be easily apparent. With central apnea, we would see diminishing respiratory effort settle into a cessation of breathing, followed by gradual increase in breathing as the respiratory drive kicks back in from a build up of CO2. Watch for the chin-tuck and respiratory effort and movement in the chest and abdomen as effort increases but apnea onsets. I have a high degree of certainty your dad will resolve much of his cyclical obstructive apnea with the use of positional therapy.

[Gideon]

I concur, the only difference I would have would be to resolve the positional with the collar first, then reevaluate and if needed increase the min EPAP,
I see the UAs as mostly obstructive and the obstructives near the UAs being fundamentally the same as the UAs and not a separate condition at this time.

[katez]

I thank you both for replying. I considered a cervical collar a few months ago but did not think I could convince him to wear it.
Now I will insist that he try it at least one night.

[Gideon]

I will add that if your dad can keep his head and neck straight thru the night he may not require a collar BUT it is unusual to correct that much with just a pillow modification. Does he use 1 or 2 pillows, if 2 get him to use one.

[katez]

He sleeps flat on his back with one pillow and we try to put something under his knees to help with his lower back pain.