(OSCAR)Help needed, with analyzing a breathing curve, any experience with this? :-)

[Letsfixthis]

Hello everyone!  

Am trying to help a parent(mommy, 72 years old) with here cpap therapy.

I have attached an example of a typical breathing curve, with the settings she currently is using. 
But since I'm not able to get the more sinus shaped curve with proper rounded edges, which is desribed as being the optimal breathing patterin.  I wonder if someone is able to provide feedback for CPAP settings to try, by just looking at the breathing curve and current settings used!   :-)
I have a suspicion that she might suffer from UARS, where bi-level is needed for optimal breathing. But I need a way to verify this for sure!   ;-)

Hope someone in here, has some experience with this!  :-)


The reason for CPAP treatment, in here case, was not high AHI numbers(about 5,2 AHI in sleep study), but long lasting apnea's (+60 seconds) resulting in blood oxygens dips in the 7x% (SpO2).

I very easily lowered here AHI number to below 1 in OSCAR using CPAP(first try actually).
BUT, after that initial succes...and initial improvement in sleep quality, there seems to be room for more improvement. As she still experiences lack of energy and the amount of sleep(especially deep sleep), varies a lot from night to night.  Suggesting my "work" is not done yet!  ;-)

She uses a Resmed Airsense 10 autoset, together with a Resmed nasal mask (N20). Using "pillow" setting, as descriebed in the manual!  ;-)
I feel like I have tried almost all combinations that her Resmed machine offers(different pressure ranges/all EPR ranges and without it, AUTO CPAP mode and just a set pressure with CPAP mode, different mask settings and humidity settings etc. etc.) but not been able to improve further beyond this point.

She recently had a heart surgery(double by-pass), which seems to have influenced here breathing some what....here AHI got a bit lower for awhile.

Hope someone can help shed some light on this topic......would be greatly appreciated!  :-D


Kind regards

Daniel

[PeaceLoveAndPizza]

The breaths are flow limited at the peak, you can clearly see the scalloping. Her flow limits in general are high, but they may have been that way for a long time, so nothing to get concerned about at the moment. The inverted I:E ratio is indicative of heavy flow limitations as well.

As far as her current setup, please post the entire evening using the link explaining formatting in my signature “Formatting OSCAR charts”. That will give a better idea of what is going on.

Typically we would recommend more EPR, but as she is already at 3 there is no place to go. To determine her arousals, we would need to see the entire nights chart, not just a zoomed in section. Overall other than the FL’s the numbers look fine, but I believe she needs more pressure support. 

We can try titrating to see what a better pressure should be, but don’t want to disrupt her sleep too much. Try the following:

Min pressure 7
Max pressure 12
EPR 3 full-time
No ramp preferred, but if she really needs it that is fine, just lower the ramp pressure to 7

I expect her pressure will swing quite a bit due to the FL’s, so prepare for that eventuality. 

There is a high likelihood she will need a bilevel to handle the flow limitations. If her insurance will cover a new machine, then we can help make the case. If you want to buy one out of pocket, you can usually find low hour used ResMed AirCurve 10 Vauto’s on craigslist or facebook marketplace. 

For now, give those settings a go and let us see where it leads.

[Letsfixthis]

Thank you so much for your feedback!   

The wording of your reply, sounds like you deal with this topic professionally as well?   

I have some more data from the past few days, plus some extra data from earlier cpap-days.

At the very beginning, my CPAP goals on behalf of my mother, was to keep her AHI as low as possible and her SpO2 levels above 92-93% all through the night(using a ring on her thumb that measures SpO2 levels every 4 seconds).

I started out, watching a couple youtube videos on the topic of CPAP, and was initially surprised at how easy(lucky) it was to reach my cpap goals.

However, that initial "boost" in sleep quality, soon proved to not be very"stable", and her sleep quality seemed to vary a lot.
Using different sleep trackers, I could see she had serious issues getting enough sleep stage cycles and make them last long enough. Particularly the deep sleep cycles.

So I quickly experimented with lower CPAP pressures and got the impression it improved her sleep quality. Perhaps in part, because it also improved her leak rates. I had her on a CPAP pressure of 5,6 and EPR 2 for a longer period, where she had several 0 AHI scores. 

I usually found her leak rates to become a problem, some where between high 8's - low 9's pressures.

I had her use mouth tape for a period, where things improved/became more stable.  But unfortunately after several uncomfortable episodes(related to nightly coughing), she refused to use mouth tape again.

Well....so now, after seeing severel people saying that "healthy" airflow curves, should have near perfectly rounded edges on the inspiration part of the curve, I took on the task to figure out if this was ineed possible.  So far, I have only seen it during the parts of her sleep where she's awake.....which fooled me a bit in the beginning. But after learning she would only get these curves when she awakes during her night sleep.....I, for awhile, kinda figured it was probably just BS advice!  


I don't know how many files I'm allowed to attach(new user) to on reply, but I find myself thinking it would be easier to just attach the original cpap data files from the sd-card, than editing and copying screenshot files!  It would also make it easier for you to see the details in the measured data?   But just a quick though on my part! 

Please see attached files....hope they provide usefull information!  

[Letsfixthis]

PS:Some more files....had to split it up!  She borrowed a "For her" Airsense 10 machine for a couple weeks. I attached a screenshot from this period as well.

---

PS 2:  Lastly, a couple screenshots from OSCAR statistics overview. So you can see the many different settings I've tried!  

[PeaceLoveAndPizza]

“Professionally”?   Hardly. Everything I was taught about CPAP was learned by reading this forum for years before finding the bravery to actually post. And even longer to try and help. The folks here are wonderful teachers. The wiki pages are full of useful tidbits worth reading.

For the chart formatting, seeing the “statistics” area on the left hand side would help with the numbers. I can tell her flow limitations are rather high visually, but seeing the actual data is better. I am not good at formatting things, but you can read the link in my signature “Formatting OSCAR charts” for what we like to use.

For your mum, the leaks are her biggest challenge at higher pressure. She may be better off with a half-face/hybrid mask, like the ResMed F30 or F&P Evora, assuming she wants to give it a go. If she wants to stay with the pillows that’s grand, but we need to find a way to handle the leaks that she is comfortable using. I don’t like mouth tape either, though we have some folks here who are experienced in using it, so I will happily defer to their expertise. A soft cervical collar is another option, worth giving a go once you have figured out the size she needs. I have attached an image that would help figuring out what size she should use. It is equally possible that at a higher pressure with EPR she will do well, so that is worth trying.

Note that a soft cervical collar may help with the flow limitations as well. It helps stop neck kinking which can occlude the airway.

From her charts, the ones with EPR 2 seem to be well tolerated. I think you could bump it up to 9 or 10 by adding a bit more EPR to help tame the flow limitation beasties.  She also seems to tolerate lower pressures well, so some of the latest charts you posted give us the clues that EPR is a good thing.

Something like:

Mode CPAP
Pressure 9
EPR 3

Or 

Mode APAP
Min pressure 7
Max pressure 10
EPR 3 full-time

For now leave her response set to soft, we can always adjust it later if needed.

On the flow rate waveforms, a nicely rounded peak is the goal, but at the moment do not dwell on it. Adding some more EPR will help with that, and hopefully be more comfortable for her as well. Give it a try for one night and let us see how she responds. We can always change it tomorrow as needed.

Be sure to ask her how she feels in the morning. Our goal is quality sleep. 

BTW, you are doing a great job with your assessment of things. Thank you for your patience as we dial in her settings to find what works best for her.