Breathing pattern identification, Flow limitations and posture

[TryingToGetItRight]

SingleH, I suggest you give them a call on the phone - they don't just sell the equipment; they are familiar with the needs of those of us who use it. They spend some hours with me trying to help me sort thru an issue where some kind of hissing noise was getting piped thru the airhose to my head and they were able to get it sorted for me. I would suggest telling them what you've told us; they should be able to help you find the best equipment for your issue.

[SingleH]

Unfortunately he struggles to breathe out against a higher minimum pressure than 13 as a baseline and too high a maximum pressure results in lots of mask leaks. This range is about as good as it gets with his current APAP machine. I did try EPR for a few days, but it didnt yield much in the way of results, perhaps because the level of 3 is not enough?

When I look at most days, I do see the machine increases pressure in response to flow limitations. I have attached another screenshot.

Based on your previous recommendations I was hoping to get hold of an Aircurve 10 Vauto as a trial but couldnt get one. The Lumis 150 VPAP ST-A was the closest option for a trial. He has scoliosis which Resmed recommend the iVAPS for, so that mode might help and I presume as it auto adjusts pressure so its the closest setting to the Vauto, if not I guess S mode is the only other mode to try?

       

[Sleeprider]

The use of EPR will reduce the expirahtion pressure, so if EPR is set to 3, the the inhale/exhale pressure can be 13/10. It is the support of increased pressure during inspiration that resolves most flow limitation, not just fixed pressure. Clearly a bilevel is the best choice, and I presume you are working the NHS. The close-ups of respiration you showed, clearly point to the problem, and confirms the Flow Limitation index suggested by the F&P statistics is grossly under-counted. Nearly every breath is flow limited. A problem this severe is not common, and in addition to seeing a more appropriate bilevel machine, it may be worth seeking a consult with an ENT to investigate the structure of the upper airway tissues that are causing this fluttering obstruction. We now know that the respiration rate is NOT 25 bpm. The machine is improperly counting as many as 2-3 breaths for each respiration cycle. If you can get access to a Lumis 150 ST-A, you have the choice of many different thrapy modes including VPAP-S, ST, PAC and iVAPS. Overall, in my opinion your friend is fulfilling respiratory needs and does not need volume assistance to maintain an adequate vent-rate, but needs stabilization of the airway during inspiration that the ST-A can provide in multiple modes. One thing we do know, the current F&P device is completely confounded by this respiratory problem and cannot differentiate even inhale from exhale. It is not close to meeting the needs here.

[TryingToGetItRight]

Based on what I know, SleepRider is entirely correct.

The odd breathing pattern is confusing the machine's algorithm because it is not distinguishing between breaths, and based on what you have said, it sounds like BiPAP may be the next thing to try.

EPR can help sometimes, but it is of limited utility compared to the pressure difference between inspiration and expiration that BiPAP is able to support.

[Sleeprider]

Just to explain why bilevel is so useful, we can use the Ti-min (minimum time of inspiration) to avoid having the machine cycle during inspiration, so inspiratory positive pressure can be sustained through the normal inspiration time. Also, the close-up view of the respiration wave as you posted on the last page will be the most valuable tool you have to help explain to doctors and clinicians the nature of the problem. If we look at the chart through the night, one could be mislead to think this is very good therapy. It is only when the respiratory wave is visualized that the problem becomes more apparent.

I have one other thing we can try. If there are sustained periods of normal respiration , that may indicate the flow limitation is positional and might respond to positional therapy options like flatter, thinner pillows or even a soft cervical collar to optimize the head and neck position to keep the airway open. This is discussed in both the Optimizing Therapy and Soft Cervical Collar links in my signature below. These normal periods can be found by looking at the Resp Rate chart and looking for respiration rate at about 12-15 bpm. These will be normal breathing without the obstructive dips in inspiration.

[SingleH]

Thanks for the info on the secondwind website, useful to know.

[SingleH]

Hi Sleeprider,

Ive tried to summarise my points to cover both your messagees.

He had a ENT look at his throat about 4 years ago although the investigation was not relating to sleep apnea. The summary was as follows:

Neck shows no lumps or lymphadenopathy, his throat was normal looking. Flexible endoscopic examination of larynx and pharynx demonstrated no lumps or lesions.

Dont know if the ENT was looking at things that could cause sleep apnea though.

I believe there is a few issues at play:
1. Scoliosis/Kyphosis resulting in:
2. Poor neck posture while sleeping
3. Limited ability to take a deep slow breath and Weak chest muscles that dont inhale or exhale in a smooth linear fashion. I did get some feedback from a respiratory specialist who thought the waveform looked like intercostal muscle dysfunction, the muscles that are responsible for expanding and contracting the rib cage when breathing resulting in erratic lung movements (he had an incision made through the intercoastals for his heart surgery)
4. His tongue falling back in his mouth as you suggested earlier on or some other kind of other cause of UARS yet to be identified.


Not on the NHS as its super slow on all this stuff so trying to get the things moving a bit quicker. I have a respiratory therapist who will assess his breathing.

His sleep study said moderate positional sleep apnea, and I think the same applies with his flow limitations.

Your comments about the collar and pillow could be a key part of it. I did give him a collar which helps as it stops his head going forward but when his head tilts back its a problem. If he sits in his chair and falls asleep generally I've rarely seen him sound like he is struggling to breathe until his head falls back and when he does on the odd occasion he sounds like thr fellow in the video below when he is breathing:

https://www.youtube.com/watch?v=fEmG2L9WCZY

You have really got me thinking, as I think this could be the cause of the flow limitations. Due to his scoliosis, he has prounounced hump in his back and when he lays down there is big gap behind his neck, He does have two pillows but I have seen it before where he has somehow got in the position where his head is tilted far back and he has his mouth wide open kind of like a flip top head. In this position he makes the strange noises like in the video and I imagine his windpipe is basically kinked. Apologies for the rough sketch ive made. His pillow arrangement might need to be altered to prevent this, maybe a cylindrical pillow. I will read your guides.

Regarding normal breathing waveforms, you do see them but its once in a blue moon, you will see maybe 3 normal looking waveforms here and there, but they probably account for 5% or less when scanning through the resp rate chart. On the odd occasion you might see a few in a row. Ive attached a screenshot.

The Lumis 150 ST-A unit will arrive soon.


   
[attachment=54951]

[Sleeprider]

The pattern just looks worse the longer you look at it. I think bilevel is part of the solution. The evaluations he has had performed and the complications from scoliosis/kyphosis as well as previous heart surgery makes this something I'm not qualified to do much more than to offer suggestions and assist with the trial and error that will certainly be part of the therapy with the Lumis 150 ST-A. Jay51 and StuartC are both current members with personal experience using that therapy, and at some point I will point them to this thread for input.

[TryingToGetItRight]

SingleH, it is very unfortunate that your father has CPAP and his treatment has been difficult, but he is rather fortunate to have someone willing to put so much effort into his care. You are definitely a resourceful person!

[SingleH]

Hi Sleeprider,

I appreciate your assistance, its been very useful and  agree that Bilevel is probably the solution. There isnt really any other avenues of exploration. The surgery he had previously was for a valve problem that was three years ago and was successful. All his heart performance stats are good and in the normal range. He has had various health checks and all his blood work is also all in order and no longer requires medication. His weight is normal and his fitness levels are good and he regularly does over 10k steps a day and plays golf regularly. The various doctors have signed him off some time ago with a clean bill of health, the breathing issue is the remaining part of the puzzle as its clearly not right, but he goes through his days generally oblivious to it.


Just one last questions going back to your comment on iVAPS, apart from the volume assistance which may or may not be needed, am I right in thinking this would be the mode closest to "emulating" the experience of a Vauto machine, as iVAPS automatically adjusts pressure (+ volume) and you can set the min/max PS and Auto epap mode, which isnt available in any other mode.