Grandfather's Results

[Geer1]

Since being diagnosed I have been trying to learn a lot and recently visited family where I was interested to look at my Grandfather's data. When I did so I saw his average AHI was around 15 and a number of those were centrals appearing during periods of periodic breathing. This chart shows a rough idea of his average nights data at that time (a bit worse then average but he had limited days with flow data available to choose from since S9 only records last 7 days of flow data). Main things I noticed were the periodic breathing centrals as well as numerous large leaks which I was told by my Grandma are from his mouth opening.

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I talked him into trying a few different changes which included turning ramp off, increasing minimum pressure to 8 cm and turning EPR off to try and reduce centrals (tried making this change while he was awake and wearing the change and he said he could barely notice the difference so left it off). I recently got 5 nights of data off of these new settings and see that it for the most part got rid of the centrals and average ahi has dropped to 5.8. One thing I noticed a big change in was his pressures which now hits max quickly and stay there almost all the night due to what appears to be near constant snore/flow limitation. 

I had mentioned to them that the mouth breathing and leaks were an issue and mentioned that he should use a full face mask as the only other option was mouth tape (he had already tried a couple chin straps and refused to wear them). I guess my Grandma decided to do her own test on this and taped his mouth shut while he was sleeping... It resulted in the following data (you can see she must have taped his mouth around 10 pm) which is a good example of these first few nights at these new settings. I have told her she shouldn't do that (I understand Grandpa had a few things to say the next morning too lol) and they have ordered an F30 mask to see if it will work for him. He had used a nasal mask in the past and doesn't like anything that crosses bridge of his nose so ideas I had were the F30, Dreamwear FFM and Mirage Liberty, maybe Airtouch F20 if none of those work.

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I am trying to get them to talk to doctor and try to arrange a titration study as his current machine is due for replacement. I am guessing he needs a bilevel like VAuto which would supply some more pressure and also give more control over PS, higher PS would likely help him but the centrals appear to be an issue so in order to do that I imagine he would need an ASV although he has some heart issues so I know that would have to be looked into to make sure he can even use ASV.  

On his current machine I don't see much a guy can do other then try to get leaks under control with a FFM and then maybe try a lower max pressure to see if the maxed out pressure is actually making any difference. Maybe reintroduce some EPR although it doesn't sound like the lack of EPR bothers him.

I am willing to help him make a few changes but am hoping they can find a better clinic/doctor (they live in a rural area and most doctors/clinics in the area are not up to par) and get a titration study to determine what machine he should be using. I am curious on your thoughts of machine selection and any other changes worth considering.

[Osiris357]

I think you have this under control until he can get to a doc with this data. How long has he been on Pap? Once his doctor sees this data I don’t think it’ll be long till he’s on the correct machine. The more knowledgeable in here may have some tips for you though.

[OpalRose]

The chart with EPR off looks much better.  CA’s at 1.5 compared to the chart with EPR 3 which show CA’s at 13.8.  If it doesn’t bother him, I would leave the EPR off.

Btw, I really like your Gramma taping his mouth shut.

[Sleeprider]

Grandpa has COPD or other restrictive pulmonary condition that created abundant flow limitation which is what is driving the CPAP pressure. In your trials without EPR, his tidal volume fell from 320 to only 240 and minute vent is extremely small. With EPR, he has abundant CA events. He needs a more advanced solution with pressure support and a backup rate to remedy the low tidal volume by providing pressure support to assist respiratory volume, and a backup rate to keep him breathing when CA occur. If he is a geriatric patient, this needs to occur with consideration of his heart health and other factors. While we don't like to see a high AHI, protecting his respiratory volume is more important!

My short-term recommendation is to limit maximum CPAP pressure to much lower levels to restore comfort and not cause him to exhale against such high pressure. You can go as low as he tolerates without significant obstructive apnea. You must lower his maximum pressure! He did not have significant obstructive apnea events in the first chart, even at starting pressure of only 6/4 pressure. I would be tempted to try a maximum pressure of 9.0 with EPR of 1, and see what you get. I really want to get his tidal volume back up to an acceptable level. This is a titration for minimum pressure, and you raise maximum pressure until the OA is acceptable, but avoid going so high that CA becomes much higher or respiratory volume drops.

Longer term, this information needs to be communicated to a doctor that is competent and interested in his sleep disordered breathing and can evaluate the suite of issues that result in such high flow limitation, low respiratory volume and tendency for central apnea with pressure support.

Consider buying a late Christmas present and get him a recording oximeter. I'd be very interested to know his SpO2 and pulse stats.

[Geer1]

I think you have this under control until he can get to a doc with this data. How long has he been on Pap? Once his doctor sees this data I don’t think it’ll be long till he’s on the correct machine. The more knowledgeable in here may have some tips for you though.

He was diagnosed in 2012 and I believe he started treatment shortly after that, he has probably fought with sleep apnea for decades now. His sleep study indicated AHI of 43 and SPO2 falling to 64%. I believe he is 82 now (somewhere around that) and a lot of his symptoms got blamed on old age. It was starting to get obvious that he was declining physically and mentally then they finally got him to start using the machine when he lays down for an afternoon rest and that helped significantly. This was the first time I saw him in 6 months and I noticed obvious improvement as have others and am I hoping some better sleep apnea treatment will help him even further.

Grandpa has COPD or other restrictive pulmonary condition that created abundant flow limitation which is what is driving the CPAP pressure.  In your trials without EPR, his tidal volume fell from 320 to only 240 and minute vent is extremely small.  With EPR, he has abundant CA events.  He needs a more advanced solution with pressure support and a backup rate to remedy the low tidal volume by providing pressure support to assist respiratory volume, and a backup rate to keep him breathing when CA occur.  If he is a geriatric patient, this needs to occur with consideration of his heart health and other factors.  While we don't like to see a high AHI, protecting his respiratory volume is more important!

My short-term recommendation is to limit maximum CPAP pressure to much lower levels to restore comfort and not cause him to exhale against such high pressure.  You can go as low as he tolerates without significant obstructive apnea.  You must lower his maximum pressure! He did not have significant obstructive apnea events in the first chart, even at starting pressure of only 6/4 pressure. I would be tempted to try a maximum pressure of 9.0 with EPR of 1, and see what you get.  I really want to get his tidal volume back up to an acceptable level.  This is a titration for minimum pressure, and you raise maximum pressure until the OA is acceptable, but avoid going so high that CA becomes much higher or respiratory volume drops.

Longer term, this information needs to be communicated to a doctor that is competent and interested in his  sleep disordered breathing and can evaluate the suite of issues that result in such high flow limitation, low respiratory volume and tendency for central apnea with pressure support.

Thanks Sleeprider, that confirmed some of my thoughts. No known restrictions like COPD but he does have some heart stuff like atrial fibrillation, maybe worth getting it looked into though as I don't believe he has ever seen a pulmonologist. 

Both before and after the changes his minute vent averaged 400, his tidal volume appears to have dropped from ~290 to ~250 and I see his respiration rate increased (hence why minute vent approx the same). I agree with lowering his max pressure, I am hesitant to go all the way down to 9 on the first go so will try 12 with EPR of 1 and see what happens. He wasn't having centrals every night so it might be able to get him up to EPR of 2 without them coming back but will try 1 for now.

Finding a good doctor is going to be the hard part but I will try to get them pointed in the right direction and provide them with some information to show the doctor once they can get in to see one. Here is a bit of data from before/after the change (started Dec 22).

Edit: I have been considering buying myself an oximeter so might do so and send it to him after I have tried it out a few nights.

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[Sleeprider]

A supplemental oxygen bleed into CPAP can make a world of difference, and an oximeter is the way to find out if it needs to be discussed with the doctor. That should be covered by Medicare, but the immediate need is to find out if it needs to be pursued and an oximeter is cheap diagnostic screening. I agree with your inclination to limit pressure to 12, and to make decisions from there. I just don't see the pressure at 20 as being good in this case, and to be honest, CPAP should never be the therapy of choice at those pressures.

You have done a good job picking up where the medical system has failed. He will be better off for it.

[Geer1]

You have done a good job picking up where the medical system has failed. He will be better off for it.

The more I learn about this stuff the more the system blows my mind. Up here (Canada) everything seems to have gone the way of home sleep studies (including my Grandfathers), no titration study, just give them APAP on wide open settings and then forget about them after the purchase... This seems to be because most of these tests are now primarily offered by private 3rd parties more focused on selling you equipment rather than providing treatment. 

Anyways I think I found a reasonable hospital run sleep center they can try to set up an appointment with. It is 4 hrs away but at least it appears to have a few decent doctors, it is probably the only good option in the province they live in (SK). 

They made the changes (12 max, 1 EPR) and we will see what happens tonight.

[Sleeprider]

He will max out auto pressure no matter what you set. I hope he is more comfortable and results for respiration and AHI are decent.

[Geer1]

He will max out auto pressure no matter what you set. I hope he is more comfortable and results for respiration and AHI are decent.

I was surprised how much his pressure changed after turning EPR off. Before doing so he wasn't maxing out every night but after EPR was turned off he was maxing out almost immediately and staying maxed out. 

Upon reviewing the data closer I see that at the higher pressures with EPR off his flow limitation was flagged as being significantly worse. Significant enough to be obvious when looking at the overview data. Before turning EPR off his median pressure was ~ 15 cm and his flow limitation median was ~0.02, 95% ~0.25, max ~0.5. After turning EPR off his pressure median is just under 20 cm and flow limitation median increased to ~0.18, 95% ~0.45, max ~0.6.

I don't know if that is because EPR was helping his flow limitation or if reducing/getting rid of a lot of that periodic breathing has just shown the underlying flow limitation issue. I am interested to see what will come of the new settings tonight, I imagine they will help piece the details together.

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[Sleeprider]

EPR is an approach we use to treat flow limits, which are a major driver of pressure increases with Resmed. EPR can also increase CA in some people and that seems to be the case here. I actually think he is a candidate for EERS which preserves some expired CO2 to prevent CA and at the same time stimulates respiratory drive to improve tidal volume.