APAP By Proxy back again.

[vsheline]

Her CA index is a fairly consistent 5. Once in a while it goes up to 7 or so or as low as 2. One night several weeks ago, I turned the max pressure down to 13 cm H20. Her AHI went up to 33.3. OA index = 27.4, CA index = 4.8, unknown = .6 and H = about .4

She has been sleeping with a backpack full of towels and tennis balls so that she can stay on her side. She does pretty well on her side. Definitely, if she rolls over onto her back, the OA goes up.

She tried pillows (P10) a couple of times and really hated them. She uses the full face mask because she is occasionally a mouth breather. She uses a homemade chin strap.

One of the problems we have had is that her head and face are very small (she is 5'2" and weighs barely 100 lbs). My feeling is that the F10 just doesn't fit her face. But, given the cost of full face masks, it's been hard to figure out which ones to order. Can any of the ladies that have very small heads/features make any recommendations for a small mask/headgear?

Hi suedanem,

A bi-level machine will definitely make it easier to breathe in and out.

It is common to prescribe bi-level machines when the patient needs pressures higher than 14 or 15 cm H2O.

There are manually-adjusted bi-level machines which use "S" (which stands for "Synchronized to patients natural breathing rate") therapy mode or Auto bi-level machines which automatically adjust pressures to eliminate obstructive events, similar to how an APAP self-adjusts its pressure.

Similar to APAP versus CPAP machines, an Auto bi-level machine will allow choice of the "S" (manually adjusted, with fixed EPAP and fixed IPAP) therapy mode or the "Auto" (self-adjusting) mode, but an "S" machine can only be used in "S" therapy mode or (like all CPAP machines) in basic fixed-pressure CPAP mode.

I think your mother needs a bi-level Auto machine, such as the Philips Respironics System One BiPAP Auto with Bi-Flex (ask for the version with Heated Tube).

Compared to ResMed machines, the PRS1 BiPAP Auto raises the pressure more gradually. It also has more adjustability than the ResMed AirCurve 10 Auto has.

With bi-level machines, the higher the Pressure Relief (Pressure Relief is the amount of pressure difference between EPAP and IPAP), the easier it is to inhale and exhale.

A likely issue with bi-level treatment, however, is that bi-level treatment can cause a higher number of Central Apneas to occur. For example, many have reported that their Central Apnea Index is much lower when they lower the EPR setting or Pressure Support setting.

What is waking up your mother when the pressure gets to 20? Is it mask burping/fluttering/leaking, or is it just that the high EPAP is too hard to breathe out against?

I use a mask liner from RemZZZs with my ResMed F10 FFM, otherwise I cannot sleep because the without a liner the mask needs to be uncomfortably tight in order to stop mask burping.

Everyone hates mask liners because the liner tends to touch the eyelashes, with is very bothersome, but after being put on (and the mask put on) one can gently push or pull or fold the liner away from the eyelashes toward the bridge of the nose, so the liner will not touch the eyelashes. Also, it is always important to install the liner so that the portion on the nose bridge curls slightly toward the mask, not toward the face (and eyelashes).

Use of a mask liner allows the straps to be less tight without bothersome leaking. A small portion of the leaking is still there (only a little) but it is not bothersome, because there is no mask burping.

RemZZZs recommends using a fresh new liner every night, but I have no problems using one liner for a week, as long as I do NOT follow manufacturer's directions to pull and stretch out the liner so that it will curl away from the face (and eyelashes). I minimize pulling and stretching and merely gently move the liner away from my eyelashes. But after about a week the liner has become too stretched out to use again without laundering and pressing. To wash used liners, one should use a small mesh laundry bag meant to hold small or fragile items which otherwise may get eaten or damaged by the washer if not put in a containment bag.

Take care,
--- Vaughn

[Sleeprider]

In your original thread, I expressed surprise your mom was not prescribed a bilevel machine, given the high pressures needed to maintain her airway. I continue to believe she absolutely needs bilevel. Auto-bilevel offers additional relief by allowing the IPAP and EPAP to automatically increase and decrease based on need.

Both Resmed and Philips Respironics offer auto-bilevel machines. They work somewhat differently, but both are effective. Resmed Aircurve 10 VPAP Auto machines always maintain the same pressure support, which is the difference between inhalation pressure (IPAP) and expiration pressure (EPAP). So if a pressure support of +5 is stipulated, then when EPAP is at 14, then IPAP will be at 19. If flow limitations and snores make the auto pressures higher, the same pressure support difference is maintained, i.e. 16/21.

PR auto BiPAP machines in auto mode allow the IPAP and EPAP to move in a range of pressure support. So you could set pressure support to be a minimum of 3 and maximum of 7 and the inhalaiton and exhalation pressures will move independently within the pressure range set for the patient. I'll look up some graphs that demonstrate the difference, but the point is, both bilevel machines work, and both offer much more pressure relief on exhale than is possible with an AUTO CPAP. I think this is exactly the tool you need, but its complexity may require some additional support.

[suedanem]

Thank you both for your support and information.Mom's not on Bilevel because her doctor is a GP and frankly, doesn't know as much as a lot of people on this board. She prescribed the APAP for mom after a home study and the APAP was what the home study company recommended for mom. Mom's been going to her for 15 or more years and likes her. I'm somewhat ambivalent about her.

Unfortunately, mom has other health conditions that require specialists and her GP keeps the specialists from causing harm. (The gastroenterologist prescribed a medicine that profoundly interacts with another medicine (prescribed by the cardiologist) that mom takes. Her GP caught the error before mom even had time to get the prescription filled.) So, she does keep a close eye on mom.

The GP wasn't willing to upgrade to a BiPAP but did refer mom to a Sleep Disorder Center on Friday. I called them today and receptionist said, "I can't find her referral. Sometimes it takes several days to get her into the system. Call back tomorrow."

So, in the meantime, I'm still reading and learning. I will take her to the sleep study consultation and I will be with her as much as possible, but especially I want to be there when/if she talks to the doctor. Mom is a little hard of hearing and can miss important details.

Thanks once again for all your help.

[Sleeprider]

We manage our 92 year old mom's care, and I understand what you're going through. Two episodes of chemical imbalance (sodium and potassium) both left her near death's door in the past year requiring hospitalizations. Both were a result of drugs she takes and had not been reviewed for a long time. I'm glad to say she is doing better than ever, but we manage the medications and have brought in some specialists that manage her medications and work with her long-time GP doctor. She loves the GP and trusts him, but we have found he does better with some oversight.

BiPAP will be a good answer for your mom, but the way you're coping now by compromising between apnea and her ability to tolerate therapy is very impressive. As you know, we take the best care of our parents as long as we can, but ultimately, they seem decide if the quality of life is worth continuing. So far, it appears we're both winning that battle of will. I also have an aunt who will be 100 on July 7, and I think we're losing that one.

Best of luck, and well-done in your caretaker role.