[Diagnosis] nocturnal hypoxemia with hypoventilation, Moderate OSA

[vgrando]

I have been diagnosed with nocturnal hypoxemia with hypoventilation and moderate OSA. While not on an APAP machine, I desaturated all night and this was not connected to respiratory events. 

I am on a ResMed Airsense 11 with the pressure set from 10 to 20 and an EPA at 3. My obstructive apneas are well controlled. However, initially, I had issues with air popping out of my mouth, which woke me up at night.  But I am controlling that by tapping my mouth and wearing a soft collar with a nasal cap mask. FFM cause peri-orbital edema. Unfortunately, I am still waking up frequently, sometimes for brief periods but sometimes for one to two hours, one to two times a night.

When I am awake during the night, I have numerous CAs. 

When I am asleep, I have low tidal volumes (80 to 200) and slow breathing, and few OA or CA. 

I am still desaturating with the APAP machine. My oxygen levels range from 80% to 95%. MY 02 ring shows that I hover on and off the 90% line.

I recently had a titration study with no recommendations for a different type of machine. 

I have read that an AVAPS machine delivers a consistent tidal pressure volume to the patient. And I was hoping that it might help with my low tidal volume. 

I would appreciate insights and suggestions on what machine would best help me.

[Jay51]

Welcome to ApneaBoard.  I had a home sleep study (Watchpat), PSG (hospital sleep study), and capnography.  They all showed hypobentilation (and some hypoxia).  I was put on the Resmed ST (A) machine after my sleep study.  If I could have tolerated it, it possibly could have worked for me (it has a back up rate - it will breathe (force an inhale) for a patience whose respiratory rate is too low.  Some people can tolerate it.  
I then moved on to IVAPS.  I could not tolerate that either, but some people can.  I am not on AVAPS (I have a Trilogy Evo ventilator).  It makes sure every single breath I take during the night is at least 500ml of tidal volume.  It has an algorithm that is self adjusting and won't let my respiratory rate get too low either.  I like it.  
You were prescribed the Airsence 11.  The VAUTO would have been a better choice (but probably would not have helped you). ASV would have been an even better choice (it bases your tidal volume and respiratory rate on your past 3 minutes of breathing).   An ST(A), IVAPS, or AVAPS may be needed in your situation - they can assure a certain tidal volume with each breath.  
I had to do a lot of work to educate my health care providers about this.  You may have to do the same thing in order to get a better, more qualified machine for your specific needs.  
I don't understand how your past sleep study concluded what it did.  They have their reasons for what they told you.  But here at ApneaBoard, I have learned so much more about better machines, etc.; and how to advocate (educate providers) for myself to get the results I needed.  
You stated, "When I am asleep, I have low tidal volumes (80 to 200) and slow breathing, and few OA or CA."  "I am still desaturating with the APAP machine. My oxygen levels range from 80% to 95%. MY 02 ring shows that I hover on and off the 90% line."  This is a great starting point for getting a better machine.  Show this data to your RT at your DME; your PCP; the people who conducted your sleep study and ask them if this is good enough therapy with your Airsense 11?  It may take some time to move up in level of machine; but it was worth it in my case.  
Continue to post your progress here in getting a better machine.  I can help you more specifically to formulate a specific plan for a specific machine.  Please ask any further questions about anything you didn't understand above or if you have new questions in the future.  

[vgrando]

Thank you for your help!

I first had an in-home study. These are the findings: 
There were a total of 51 respiratory events (RE), which included 17 apnea (17 obstructive, 0 mixed, 0 centrals), and 34 hypopneas.
The total Respiratory event index (REI) was 6.50 per hour at 3%, REI was 4.33 per hour at 4%.
Multiple airflow fluctuations were noted.
The lowest SPO2 was 76.00%, and the time spent <89% was 428 mins.
The oxygen desaturation index was 17.07 per hour.
There was a concern for significant non-apneic desaturations during this study.
There were PTAF channel artifacts during this study.
 

[Jay51]

Thank you very much for that summary.  The good news is that you have 0 central and mixed apnea.  Possibly some of your hypopneas could be though.  This type of hypoventilation (strictly from obstructive apnea is much easier to treat usually.  The current machine you have could possibly even do the trick.  
You most likely have a positional element to your OSA (if you SPO2 tanks down to 76 or so), but not necessarily.  A soft cervical collar could help you a lot.  Just measure from your chin to your upper chest bones and use that # for the size of your soft cervical collar (if you wan to purchase one).  
There is still possibility though that even if you completely correct all positional obstructive apnea, you still could be hypoventilating.  But based on your sleep study, if they prescribed you the Airsense 11, they may have seen this. 
It should be fairly straight forward as to how to proceed from here.  1.  Try a soft cervical collar and see how much improvement you get (especially with your SPO2 levels).   If you sleep on your back, you may want to try a night on your side just for comparison also.  Then, if soft cervical collar doesn't improve things enough, you can show the results to RT at DME, PCP, and sleep stecialists to show them that the Airsense 11 is not working for you.  If you are going through insurance (like I did and still am), it is necessary to fail at a certain machine in order to be moved up to the next level machine.  Just the way the system works.  That is the plan that has worked for me.  It takes some patience, but it can be done.  
Any other questions or clarifications needed just post again.  I, or someone else, would be happy to try to help you if we can.  
Oh, based on the time you spent below 89% spo2, it seems you qualify for supplemental oxygen at night also.  According to Medicare (and most other insurance companies use these same numbers) if you are below 88% spo2 for greater than 5 minutes, you qualify.  Ask and advocate for this if you so desire.

[vgrando]

"I do not want to be on both oxygen and an APAP machine if there is an alternative. 

So taking your advice, I have begun the conversation with my sleep doctor and messaged him this. 


I am concerned that my current APAP machine is not addressing the sleep problems that I have enumerated below. I would like you to consider ordering me a machine that will address my low tidal volumes, which should improve my desaturation issues.  I believe that a machine that provides pressure support, such as an SA-T machine, could help.  I am writing you because I do not want to my next visit in August to address these problems; thank you for your support, Victoria

1) I cannot tolerate the APAP machine at the pressure you prescribed, as evidenced by the APAP machine waking me up all night long. I frequently get only three hours of sleep out of seven-plus hours in bed.

2) My nocturnal hypoxemia, which is not being adequately controlled with my current APAP machine.  My Titration study showed that I desaturated below 89% for over 90 minutes on the CPAP machine. I desaturated below 89% for over 2 hours last night with my pressure set from 10 to 20, as you prescribed.

3) My hypoventilation, which is not being adequately controlled with my current APAP machine as evidenced by my low tidal volumes when I am actually asleep using the APAP."

[Jay51]

Excellent job Victoria.  You are being proactive, assertive, and advocating for your needs.  Your information is loaded with specific details and numbers and facts.  

The ball is now in his court.  There may be more back and forth messaging between you both to sort things out.  Being proactive like this can get things accomplished quicker. 

Please continue to post updates on how it is going.  I (we) can help you to the best of our ability with future specific communications with your sleep Doctor if you don't get the results you need to your satisfaction. 

Just from my personal experience also:  the more facts and relevant data that you give him, the better your chances of getting adequate changes to your therapy.

[vgrando]

I appreciate your support! He has already gotten back to me and, to my shock, has looked at none of two months of sleep CPAP data. Even worse, he does not believe me when I report what I see. And, of course, he is telling me that I cannot change my settings. But he did call me, and this is the being of our back and forth. He must have been shocked to see what I wrote to him. But he does not listen to me.  I am a retired nurse who has practiced for 58 years. I will not be bullied.  I have a great story that a night shift nursing supervisor shared. One night when a patient went "south," they needed the patient's doctor to come to the hospital. He refused, so she sent the police to his home to bring him to the hospital 

[Bruce Reynolds]

 my sleep doctor ...

What is his background?  If it's not pulmonology you need to see a pulmonologist.

If it is pulmonology you need to see a different pulmonologist.

Do you have a recent ABG and PFT?  What are the details of the capnography?

[Jay51]

Great questions by Bruce Reynolds.  There are several more options to take if this particular sleep Dr. is not willing to listen to you.  You can get a new Sleep Dr. (your insurance should provide a list of all the in network sleep Dr.'s)   You could also try going through your PCP (that is what I did). As a retired nurse, you know more about the healthcare system than most people.  

I had a home sleep study done 1st.  A Sleep Dr. interpreted the results.  I had a 10 or 15 minute zoom meeting with his PA.   That was it.  I learned nothing.  (I only had this done to see if I had any apnea at all.  If my results showed little or no apnea, I would not have gone to my PCP). 

I then went to my PCP (with the results of the home sleep study - 42 AHI in hand) and she wrote the script for a PSG.  An RT did my PSG.  PSG was 32 AHI.  

PCP and RT talked about results and PCP wrote script for machine.  Long story short:  I went through several machines (failing with all of them) to get to my current Evo ventilator.  

I have a Pulmonologist also.  The way it worked for me is the PCP has the most of the authority.  Her scripts dictated everything.  Also, Pulmonologist can write scripts to.  RT follows both the scripts from PCP and Pulmonologist (my Pulmonologist specializes in sleep apnea treatment.  He is like a Sleep Dr. (but much better IMO).  

I have read some negative posts here about Sleep Dr.'s.  It may take some work and time to find a good one.  Going through PCP might be much easier and better.  

Don't give up.  You are very early in the process.  Several more things to try.

[vgrando]

[attachment=51095][attachment=51096][attachment=51095]

Hi, he is an MD with a specialist in neurology/sleep and I have a Pulimologist also. I do not think either has seen my data. I will ensure that the Respiratory company, AeroCare, also sends both the data. Part of the problem is that my internist ordered me an APAP machine set from 5 to 20 with a full mask after my diagnosis of moderate apnea before I got an appointment with the sleep MD. I think he is getting the follow-up reports. 

I live in a small college town with Med Center. So MD choices are limited. I did find a sleep specialist MD out of the Med Center system. He also has a specialty in Pulmonology. I see him in July. So, I am hope full. If I have to, I will drive to KCMO for my doctors. It is a 2-hour drive from me. I worked in KCMO before retiring and have a great cardiologist there. 

I had a horrible first month until I learned how to control my mouth leaks.  They are better but not gone. I have a V-Com coming. It should help with the mouth leaks. I get peri-orbital edema from FFM and leak like crazy from cradle nasal masks and I feel like I cannot breathe. I think that the nasal cap masks are my best choice.