Got the cpap dialed and AHI is great! So why so tired after so long?

[tastyratz]

Patient is mid 40s overweight female with severe brain fog, exhaustion, and unsatisfactory sleep quality.

Did watchpat study and received Apnea diagnosis with 16ahi, 127 events and 154 rdi respiratory disturbing events.

Started with aircurve 10 treatment and adjusted pressures and tried different masks until results improved in OSCAR. Settled on bilevel mode ipap 9 epap 5. This was just over 1 year ago.

After adjusting to treatment sleep appeared to improve at first which improved overall symptoms. Did not reach normal/baseline but it seemed promising. It's definitely helping and on nights the machine isn't used it shows. Unfortunately, however, there is still just not a feeling of restful sleep and a need for frequent daytime naps.

Hoping for some insight. I've attached last 2 night's oscar screenshots.

Appreciate your time reading this!

[mesenteria]

I don't see a lot that needs improving.  Does the subject have an assessment of current sleep quality outside of breathing concerns....REM, deep sleep, time in each or percentage, wakefulness, etc?  How about O2 sats over the duration of PAP usage...anything you can share?

[Deborah K.]

I suggest turning off ramp.  At 5 minutes I don't think it's needed, and every time the mask is removed, ramp starts again, robbing one of therapy.

Also, it would be good to reset the pressure settings, as 5 is too low, as is 9.  I suggest 7 Epap and 13 Ipap.  Try that and see how it goes, then post again and we can re-assess.

I notice a big gap in sleeping.  It might be best to stay on therapy and in bed in hopes of falling back to sleep.  Sometimes that works.

Again, welcome, and best wishes for great therapy and comfort!  

[UnicornRider]

Is the split session due to taking a nap in the afternoon? Or is it the Patient trying to acclimate to wearing the mask and therapy pressure? Either one I encourage. At the bottom of the left hand panel under Session Information you can select which sessions you want to display & score for AHI/RDI. in your OSCAR Reports. For our purposes if you unselect the afternoon's session we get a more useable view of the nights OSCAR Report.

If she feels the need for a nap, encourage her to utilize the PAP therapy every time she is tired.

Post a copy of her sleep study with personal information redacted such as name, address, phone,

In your OSCAR Report of 10 March could you post a zoomed view centered around the breathing disturbance at ~0215.

It is possible she is having events not scored by her machine, such as UARS.

Can you monitor Pulse & SpO2 during sleep?

[tastyratz]

Much appreciate everyone's time and thoughts so far! I'll try and address what's been mentioned.

I just grabbed a couple non-specific recent days before posting, I wasn't trying to zoom in on anything when taking screenshots.

The 5 minute ramp there was added as a quick subtle comfort boost when getting the mask on. It's small but seemed to help settle in. They don't typically get up at night or take off the mask so it usually only shows 1 ramp per session.

Will have to dig for original sleep study results last year and come back.

O2 was measured with a finger pulseox several times and nothing notable was found but there is no recent correlated data there. There is a nightly sleep heart rate and o2 from a newer smart watch which isn't as granular and accurate but never did show any notable drops or events.

Sleep quality is poor, patient does not wake up feeling at all rested and usually takes an afternoon nap. They do wear their mask during naps. That would be what was observed as a gap when sleeping.
They have 100% compliance with their machine and have not adjusted settings in over 1 year.

Originally, the pressure rates when raised and higher were resulting in lower compliance and comfort. Patient reported lower sleep quality and tolerance. This was over a year ago at this point, however, and early in therapy.
They reported a lot of difficulty breathing out. At that point they had an older machine without data that could be pulled into oscar so it pre-dates what I could pull up.

I added the 9th just to add another screenshot day here but without the nap checked to clear confusion and zoom in on just the evening.

I also know it was requested a zoom in on the event around 2:15 on the 10th but there was not an event on the 10th, it was on the 12th. I zoomed in on that one and attached in case that was what was meant?

Will try bumping it again just to see what happens tonight.

[UnicornRider]

Hang in there, you are doing great. I know how hard it is trying to help somebody else with their PAP therapy, interpreting for another person does complicate things, but we will work through this. 

A few questions that will guide my thought process.

 Overweight, what BMI are we dealing with? 

EPAP At 5.0 cmH2O seems low for stenting a "normal BMI adult" throat open, if her BMI is high it may take a few more cmH2O to stent her throat. as higher BMI usually carry extra demands to stent the throat. My own personal experience.

She has been on PAP therapy for over a year, She has acclimated to the PAP Therapy pressures, her tolerance to PAP therapy has built up, her body may require more pressure for IPAP to be effective..

Rather than run as a BiLevel, take advantage of the auto feature, to provide a limited range of IPAP increase. 

 You could try Mode:          VPAPAuto
                     Min EPAP:     7.0 cmH2O
                     Max IPAP:     13.0 cmH2O
                     PS:                4.0 cmH2O
                     Cycle:            Medium
                     Ramp:           OFF
                     Smart Start:   OFF
                     Trigger:          Medium


Her pressure would start low and never exceed 13 cmH2O. If that is too much for her, you can adjust IPAP to a lesser value.

Or...You can actually clamp the values of Min EPAP & Max IPAP in VPAPauto Mode so tight, you effectively are running the same BiLevel pressures she is on right now. Then incrementally increase Max IPAP by 0.20 cmH2O at a time, to allow her to acclimate to a higher value. The ResMed will only provide the Max IPAP you set, if needed, otherwise it will remain at the lower values.

Let me know how you would like to approach Machine settings.

Thank you for the Zoomed in view, I can see some breath wave shapes that are distorted, indicative of a Hypopnea Event. 

There are some sleep disturbed breathing conditions that are not recorded as "Events" by the ResMed algorithms. My previous request for a zoomed in view, was for a suspected Non Flagged Event. I want to know not only what the machine is telling us is a notable event, but also what their algorithms do not catch.

  So from my previous post: 

  " In your OSCAR Report of 10 March could you post a zoomed view centered around the breathing disturbance at ~0215.

It is possible she is having events not scored by her machine, such as UARS."


Your ResMed did not flag it, but it is there.

We can utilize such non flagged events to fine tune her PAP Therapy for optimized performance.

Could you post the requested view from the 10 March OSCAR Report?

As always any questions, concerns or comments, please post back.

[greatunclebill]

realize that cpap doesn't cure all that ails you. you may have another problem, diagnosed or undiagnosed that produces your symptoms.