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Understanding Dad's data
#1
Understanding Dad's data
First off, A big thanks to all the folks who have already given me great advice. After getting a sleep study myself I realized that my dad (90 yrs) probably has sleep apnea also. He was interested in finding out more so we set him up with a sleep study. I have helped him try several different masks. He currently uses a nasal mask and a chin strap. After some help, he is wearing it almost every night. I have been looking at the display and his myair page. The other day I downloaded his data from the SD Card and loaded it into OSCAR.
Some observations, data, and questions.
1) The seal indicator on his Resmed AirSense seems to be very generous. On the display in the morning, it regularly says that he has no leakage problems but looking at the data that is clearly not the case. 
I will tighten up his masks and chin strap a bit. (any advice on tightening other than until the leaks stop but not too tight?)
2) Does the display refer to just the recent past or is it reflecting the entire night?
3) It appears that his Apnea is clearly not well treated. See data below.
This first graph is an example of a relatively good night w.r.t. AHI It is a full night in the standard chart view
   
4) This is an advanced view of a close-up of CA events.
   
5) I have other closeups of H, RE, and UA events. All of the events look the same to me. I can post them that are of interest.
6) This is a typical day with high AHI 
   
7) Given how poorly treated his apnea is, I'm wondering if I should be disappointed in his doctor for not following up closer. The durable medical equipment supplier is the only one to follow up and that has been about paperwork and once to remind him to wear his CPAP. Thoughts?

P.S. As someone said 90 years is a good run. He has been a maker and a doer all of his life and does seem to be interested. I think it is and net-positive and it gives him and me a project.

Thanks in advance for any advice.
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#2
RE: Understanding Dad's data
Looks like there is a big leak issue with his mask. You need top ensure that he can maintain a comfortable but firm sealing of his mask.
His central apnea events look pretty severe, judging by the close up chart view. He pretty much breaths for one minute before stopping for an entire 30 seconds. THis will not only rob him from a restful nigh asleep, it could potentially also bring his Oxygen saturation levels down (anything less than 90% is considered pretty dangerous).
So try and equip him with a ring type Pulse Oximeter, one that he can comfortably keep on over night and then chart his oxygen levels.
The most effective machines for Central apnea therapy are ASV type machine (significantly more expensive than the most expensive PAP machine).
ASV machine constantly monitor and analyze "each breath" and adjust their pressures and flow automatically based on the data received from each breath. This way an ASV machine will breakup a Central Apnea even "before" it is triggered, keeping the maximum period of nonbreathing , well under 10 seconds at a time. This way episodes are reduced to zero every sleep period.
Good luck.
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#3
RE: Understanding Dad's data
Your dad shows symptoms of central apnea and cheyne-stokes respiration. Whils ASV would be a logical therapy choice, it would require testing for heart failure and left ventricular ejection fraction (LVEF) to screen for risk factors for ASV therapy. CPAP is approved for obstructive sleep apnea, which does not appear to be the case here. I don't think DIY therapy is a good choice for a 90 year old man with the symptoms we see on these chart. You indicate that your dad had a sleep test. The results from his therapy clearly suggest he is not using an appropriate therapy solution. He needs a titration test that evaluates efficacy on ASV after screening for heart health and LVEF.

Please turn off EPR and use straight CPAP pressure in a range from 4 to 7. This might possibly look different without EPR, but I am extremely reluctant to advise in this therapy given what we see. Please post results of his sleep test.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#4
RE: Understanding Dad's data
I looked back at some older data. When the pressure was set to 11 and EPR was off he was having a hard time getting more than a couple of hours a night. It seemed that he would get Cheyne Stokes whenever he got more than a couple of hours of sleep. When he did it looked like this.
   

We turned on EPR in an attempt to make it more comfortable. He was able to get many more hours most nights. Here is an example.
   

He was still uncomfortable so we tried APAP
   

There is a lot of variability in the data so I would not look for any trends in these three screenshots


The results of his sleep study are quoted below.

After talking to mom and dad it appears that he has not been using his chip strap. Mom is going to help him remember to use it.
I also tightened the chip strap and the mask. 

I turned EPR off and set the pressure to 7

"Indication: OSA


Clinical Information: Height: 65.5 in. Weight: 143.0 lbs. BMI: 23.4

Test Description: Split Night Polysomnogram

Mask: Amara View med/med Size: Amara View med/med Headgear: Standard Heated
Humidifier: (Y) Chinstrap: (Y)
Titration Unit: Respironics

Monitored: Frontal, Central, and Occipital EEG, EOG, Submentalis EMG,
Oronasal Thermocouple, Nasal Pressure, Mask Flow, ECG, Thoracic and Abdominal
Respiratory Inductance Plethysmography effort belts, Right and Left Anterior
Tibialis EMG, Snore Sensor, and Pulse Oximetry.

Scoring: The tracing was scored in 30-second epochs according to The AASM
Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and
Technical Specifications Version 2.5.

Sleep Staging and EEG Analysis: Lights Out was 21:22:01 and Lights On at
02:29:57, with a Total Recording Time (TRT) of 308 minutes. The patient slept
for 154 minutes, yielding a Sleep Efficiency of 50.0%. 154 minutes of sleep
out of 502 minutes of total recording time occurred on the baseline portion
of the study. Sleep Latency was 08 minutes with a REM Latency of 202 minutes.
The patient spent 32 minutes (20.8%) in Stage N1, 121 minutes (78.9%) in
Stage N2, 0 minutes (0.0%) in Stage N3, and 00 minutes (0.3%) in Stage REM.
The total time Awake After Sleep Onset (WASO) was 146 minutes. Any EEG
findings considered significant or abnormal will be further discussed in the
interpretation below.

Arousal Events: An arousal is defined as abrupt shift in electroencephalogram
frequency, including theta, alpha, or frequencies greater than 16 Hertz, but
not sleep spindles, lasting three seconds or longer. In REM sleep, these
changes must be accompanied by a concurrent increase in submentalis
electromyogram amplitude lasting at least 1 second. There were a total of 45
arousals with an Arousal Index of 18 per hour of sleep.

Cardiac Events: The average heart rate (HR) during sleep was 54.0, normal
sinus rhythm. The highest HR during sleep was 57.0 with a minimum HR of 50.0.
The highest HR during the entire recording was 69. Any ECG findings
considered significant or abnormal will be further discussed in the
interpretation below.

Movement Events: Periodic leg movements are defined as defined by movements
in the anterior right and left tibialis channels of 0.5 to 10 second
durations, in trains of at least four movements, with intermovement intervals
of four to 120 seconds. The total number of periodic leg movements during
sleep was 0 with a PLM Index of 0.0 periodic leg movements per hour of sleep.
The total number of periodic leg movements with arousals was 0 yielding a PLM
Arousal Index of 0.0 arousals per hour of sleep.

Respiratory Analysis (Baseline/Diagnostic Portion ONLY): An apnea is defined
by a drop in the peak thermal sensor excursion >90% of baseline for 10
seconds or more. Hypopnea are scored using both rule VIII.D.1A (A hypopnea is
any decrease in airflow >30% of baseline for ten seconds or more that is
either accompanied by a >3% decrease in oxygen saturation from pre-event
baseline or associated with an arousal) and rule VIII.D.1B (A hypopnea is any
decrease in airflow >30% of baseline for ten seconds or more that is
accompanied by a >4% decrease in oxygen saturation from pre-event baseline).
The apnea hypopnea index (AHI), is calculated by dividing the total number of
apneas and hypopneas by the total numbers of hours of sleep.

Under Hypopnea rule VIII.D.1A, the Apnea/Hypopnea Index (AHI) was 71.7 (Apnea
Index (AI) was 67.4 and the Hypopnea Index (HI) was 4.3). There were a total
of 184 respiratory events consisting of 12 Obstructive Apneas, 11 Hypopneas,
0 Mixed Apneas, and 161 Central Apneas. There were 0 RERAs resulting in an
RDI of 71.7. Supine AHI was 71.7. Nonsupine AHI was 0.0. NREM AHI was 71.9.
REM AHI was 0.0.

Under Hypopnea rule VIII.D.1B, the Apnea/Hypopnea Index (AHI) was 70.5 (Apnea
Index (AI) was 67.4 and the Hypopnea Index (HI) was 3.1). There were a total
of 181 respiratory events consisting of 12 Obstructive Apneas, 8.0 Hypopneas,
0 Mixed Apneas, and 161 Central Apneas. There were 0 RERAs resulting in an
RDI of 70.5. Supine AHI was 70.5. Nonsupine AHI was 0.0. NREM AHI was 70.7.
REM AHI was 0.0.

Snoring was rated as . The Mean SpO2 during the diagnostic portion was 92.0%
with a minimum SpO2 value of 79.0%. The percentage of Sleep Time with SpO2
at, or below 88% was 16.7. Cheyne Stokes breathing was not observed.

CPAP Titration: The treatment portion of the study was a CPAP titration
utilizing the settings of cm of water. The CPAP setting of cm of water was
effective in treating the Obstructive Sleep Apnea. The AHI was at this
setting; minimum SpO2 was %; and no snoring was heard.

Interpretation: The diagnostic portion of the sleep study demonstrates
central, obstructive and mixed sleep apnea; CPAP of 11 cm of water appears to
treat the patient's obstructive sleep apnea howeve wass not tested in REM
sleep

Recommendations:
1) The CPAP setting of 11 cm of water is recommended for treatment of the
patient's Obstructive Sleep Apnea.
2) If the patient is over the ideal body weight, weight loss may help improve
the underlying OSA and could serve as adjunctive therapy.
3) The patient should be cautioned that sedative/hypnotic medications as well
as alcohol could worsen OSA.
4) The patient should refrain from operating a motor vehicle or heavy
machinery if sleepy and avoid driving until any subjective sense of
sleepiness has resolved and has been adequately managed.
5) Clinical evaluation is recommended within 3 months from initiation of
positive airway pressure therapy to assess patient acclimation and compliance
to this setting and further assess its efficacy."
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#5
RE: Understanding Dad's data
I rad in the report that ": The diagnostic portion of the sleep study demonstrates
central, obstructive and mixed sleep apnea; CPAP of 11 cm of water appears to
treat the patient's obstructive sleep apnea howeve wass not tested in REM
sleep"

That is consistent with not seeing the Cheyne-Stokes breathing until 90 to 120 minutes on sleep. Could it be that they missed it in the study?
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#6
RE: Understanding Dad's data
It's obvious that your dad was diagnosed with predominately central apnea and hypopnea. Please have his heart health and specifically his left ventricular ejection fraction checked. If within acceptable range, he should be moved to ASV. The sleep report suggested clinical follow-up in 3-months. You should forward the information you have presented in this thread to that physician and ask that the follow-up be expedited, and ask him what the path is to ASV in terms of additional examinations and testing. CPAP has resolved obstructive sleep apnea, but left the central apnea untouched or perhaps worse. The CPAP titration indicates OSA is controlled at 11.0, however we are seeking a pressure that mitigates OSA but does not result in higher CSA.

Speak with the doctor and arrange the next follow-up as soon as possible. Meanwhile, the objective needs to be to find settings that are as comfortable as possible for your dad. We have seen CPAP results in central apnea clusters regardless of the use of EPR, however it may be worthwhile to use a low EPR of 1 for comfort. Fixed pressure at 7.0 with EPR 1 may be the best compromise. I don't think your dad should accept an central sleep apnea index in the 40s without fully investigating whether he is a candidate for ASV which will fully treat this.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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