gaffer therapy thread

[gsaffer]

Hello. I've been bouncing around the forum for a couple weeks and it's time for me to ask for HELP. 65 yo male 5'10" 210 and in above average physical condition. Live at 7360 ft elevation. Had some cardiac issues (atrial flutter) in Feb which triggered a 14 day heart monitor revealing some other issues that cardiology attributed to sleep apnea. Consequently had an in clinic sleep study after disregarding a home study as I was continuing my denial of sleep apnea at the time. I'm in and out of atrial flutter with ablation scheduled for August 7. Cardiology is convinced the flutter has no bearing on the apnea or vice versa but apnea was contributing to low blood pressure and low heart rate/ bradycardia and some early morning A/V blocks. 

Airsense 11 with Dreamwear FFM and CPAP pillow. Side sleeper and nose breather. My numbers are all over the place. Started CPAP on May 26. Posted below my best night from June 10 and one from last night June 22. The nights in between are erratic with zero consistency. Feel like I'm on my own- doc is not helpful and apnea seems as individual as fingerprints. Thanks in advance for your input!

Sleep study was not long but they thought long enough for results. Couldn't sleep all wired up. 451 minutes in bed and 241 minutes asleep. After seeing my Oscar charts I'm wondering how helpful the study really was for that short a time. Doc thought it adequate.  

Clinical Sleep Study Results:                                                                  Home study results (6 hours):
Apnea/Hypopnea Index: 16.9                                                                AHI:15.5
Central Apnea Index 2.5                                                                       RDI: 17.9
Apnea (central, obstructive and mixed) index: 4.7
Hypopnea Index: 12.2
RDI: 16.9
REM AHI: 14.7

[Deborah K.]

I see a couple of changes that should help.  Your median pressure is over 8, and you are hitting your top pressure, so change your pressure range to 8 to 15.

Also, to lower your flow limits, turn EPR on full time, set at 3.  Most folks find that makes their breathing easier as well as lowering flow limits.

You are having a little Positional Apnea as well. PA shows on your chart where obstructives and/or hypopneas are clustered together. Yours is not too bad, so maybe sleeping on a flatter pillow will solve it. If not, you may need to wear a soft cervical collar.

The one night you had extremely high CAs. The other you had only a few. Did you have a lot of them in your sleep study? If not, they are treatment-emergent and will lessen as time passes. My guess is that they were not high, or I think they would show up every night.

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

[gsaffer]

Thanks Deborah- I'll try that tonight.

I had EPR at 2 a couple nights ago and got the below so I dropped it back down thinking it perhaps was the EPR driving the higher CA's. Not an educated guess by any means- just a guess. Sleep study showed Central Apnea Index at 2.5

[gsaffer]

Well that didn't go well  . Made the changes to pressure 8-15 and EPR 3 last night. Woke up exhausted with elevated numbers. Perhaps EPR isn't for me? My best results since I started have been with EPR totally off. Min pressure at 8 works (maybe could go to 9?) and looks like I could do 12 at the upper limit. Last night's data below. Would love to rediscover the results from June 10 from my original post or somewhere close. Thanks again in advance for input!

[gsaffer]

I turned off the EPR last night and things moved back in the right direction. Still messy but better and felt far more rested this am. Mask felt like it was leaking like crazy and I couldn't fix it so took it off early and went back to sleep. Oscar posted below- still love to have some input on improving things. Thanks!

[gsaffer]

Hello again,
Could sure use some help. Been just over a month and still no consistency. The Dreamwear FFM is nice with top hose and minimal mass but seems to leak a lot. Ordered an F20 Airtouch and will see how that goes. Trying to heal from some spinal procedures and the lack of quality sleep is not helping. Below are a few recent days results. Honestly need some guidance as I felt much better before starting therapy.

[SarcasticDave94]

Probably obvious, but the CA are an issue, despite not showing many on the sleep study. CA will be pretty random, called consistently inconsistent. Your higher elevation may increase likelihood you'll have the CA to deal with.

Try for a night unless it goes badly: pressure 9-11 no Ramp no EPR. Attempt to almost be static pressure so the CA might diminish if they're variable pressure induced (possibly not with as many as you're scoring).

The sleep study was done at similar elevation as your home?

You're likely needing to request the doctor to change machines for you via a new script. The ResMed AirCurve VAuto is the likely next step. It can avoid more CA as it has some timing settings like Trigger, which can increase sensitivity to switch into IPAP inhale.

Be prepared though, this may not be enough. Depending how badly and consistently your CA are, you might need to actively treat these with ASV. Check with cardiologist as well on their thoughts.

[super7pilot]

Part of the issue could be the high elevation. High elevations are known to produce more CA's than you otherwise would have. Was your sleep lab done at a similar altitude to your home location?

And the fact that the cardiology Dept said Apnea causes LOW blood pressure. Um, That's scary as heck. They should go back to school.

Looking through your OSCAR charts. You did pretty well on June 10th & June 28th. If you don't need EPR for comfort. That might be a better thing for those CA's. But the lack of EPR can result in more Flow Limits. I would stick with the basic settings of those two days. As you are new to therapy. Your numbers 'can' be all over. It just varies from person to person.

There are a few things that are not helping you.
1, High elevations makes folks more prone to CA's. Remember that adjusting an AirSense to lower CA's will generally result in increased OA's & H's. CA's are treated with an ASV, which will also treat OA's & H's. As CA's were not as prevalent as the OA's & H's. Insurance likely wouldn't cover the $6K ASV machine.

2, Being new to pap therapy can make you prone to CA's. Treatment emergent CA's are a thing, and will generally improve as your time in treatment increases. But the high elevation can illicit CA's

3, Being new to pap therapy. It can take some time for the body/mind to adapt. We humans are not designed to breathe pressurized air. It simply takes time to adapt.

4, You are likely under a lot of stress from the heart issue and upcoming abaltion. Stress sucks and doesn't help with getting good sleep.

5, pap therapy and sleep hygiene are very much connected. Don't read, watch TV, monkey with the phone in bed. The bed is for sleeping & adult fun time, and nothing else. Get your pap equipment ready to go, cleaned and water added long before you get ready for sleep.

[Deborah K.]

You still need to deal with your Positional Apnea.  PAs show on your chart where you see obstructives and/or hypopneas clustered together. These are caused by your chin tucking toward your chest.  No setting change will help.  Some people can solve this by sleeping on a flatter pillow, or without a pillow.  Many need to wear a soft cervical collar that is high enough to keep their chins up.  You can find a few at most pharmacies, and lots of them on Amazon.  Many here like the Caldera Releaf Collar, as it is quite comfortable, but folks with long necks sometimes find the collar is not high enough for them.  Others like the Velpeau collars and lots of others.

Best wishes for solving your various issues!

[Sleeprider]

With the CA events and periodic breathing, it looks like ASV therapy would be your best bet. Take a look at CLCCW's therapy thread https://www.apneaboard.com/forums/Thread...-Questions This member is in Colorado and faced similar issues, but eventually managed to acquire an ASV device. We can discuss buying a used ASV on DotMed to expedite the process, but I think you are going to follow in the same footsteps as CLCCW.