Help for father

[SonofBiPAPuser]

Hello, 

My father has a ResMed AirCurve 10 VAuto.  He has several health problems.  Currently he has an Oxygen Concentrator supplying 4 L/min to the AirCurve.  He has a history of heart trouble (CABG) and he has compromised lung function - approx. 35% due to combination of things (frenic nerve nicked in CABG years ago (we believe), reducing the function of one diaphragm, together with pulmonary fibrosis and/or asbestosis).  And he has apnea.

I decided to get more involved in his care after he ended up in the hospital a couple weeks ago.  He was walking around with SpO2 < 85% and his primary care doc told him to go the hospital. I'll skip the hospital details, but his gap on his OSCAR usage is because he was using hospital or rehab nursing home equipment. 

Possible relevance:  his O2 concentrator was not working properly for some - unknown - amount of time prior to his hospitalization.  It could have been months, it could have been days.  There is no way to know.  It had warning lights, could have been at 0% or 90%; I don't know.  Obviously I worked with the DME to fix that, and I ordered a new one, which we'll get in a week, just to have a backup.

Based on advice from this board, I ordered a Wellvue SleepU SpO2 & HR monitor which I will get tomorrow.  I got the clinical manual - thank you!  

He has a sleep study scheduled for next week.  Today I downloaded OSCAR and his BiPAP data and I have made some plots.  Note that one night - 7/7/21 - I changed the mode to VAuto but then I got scared and changed it back the next night.  

I included some 1 year data because his response seems to have changed a lot - recently the AHI's have been much higher than 6 - 12 months ago.

I am trying to get smarter so I can help him.  Adjusting these things is beyond his ability.  I want to be educated enough to know if whatever the sleep study advises is reasonable, and I want to be able to help dial in his settings.  I don't even know where to start.  

If any of you kind people can look at these plots and read this long email and share your thoughts, I would be sincerely appreciative.  Thank you!
           

[SonofBiPAPuser]

I saw I was only supposed to upload 3 plots so I didn't provide the other 2 that I made. So my comments on the 7/7 night and 1 year data probably make no sense to the reader. Sorry about that. I am trying to follow the rules.

[Gideon]

Welcome to the forum.
First, his leaks are out of control. Read the Mask Primer, see my signature. His leaks are mask leaks. You can tell because they are all spikes. Mouth breathing shows as plateaus

Most likely either the mask doesn't fit him, or the mask is too tight (very common) or too loose. It could be and old cushion on the mask as well.

I would like you, the son, to try the mask on and under pressure. Don't use the straps, just hold thessk on place with your hand. Move it around, bring it closer to your face and further away. You will find and feel what works and what doesn't. Straps should match what your hand did and not crunch it down to stop a leak. If you have to crunch it down it is the wrong mask, either the wrong size or just the wrong mask.

See how the UA events are bunched together, that indicates you dad is likely tucking his chin and thus kinking his airway. This is a fairly common problem. Simple cases of this can be resolved with a pillow modification, using 1 pillow instead of 2, or using a flatter pillow, not the full form foam one. In this case I don't think that will work, but go ahead and prove me wrong. The better fix is a soft cervical collar. .see the Wiki, link in my signature. Warning, most do tors don't know this and will say not too. It really works well, see the before and after screenshots in the wiki, this works well

[SonofBiPAPuser]

Gideon, I sincerely appreciate this advice. I will work on these things and read the links before replying more fully. Possibly I’ll buy a collar.

I think it is truly wonderful that people with expertise and knowledge are willing to help others. It is special. Thank you!

[SonofBiPAPuser]

My father is making some progress.  Thank you for the help so far on this forum.  Also from reading the Wiki and downloading & using OSCAR, I feel like this forum has made an enormous difference.  Thank you!

So far I have been focused on coaching my father to reduce mask leaks, and I've also been modifying his pressures downward.  I also set Trigger to high and Cycle to low back on 7/13.  (My reasons: his Obstructive apneas were low, and his inspiration is weak.  Not sure if my reasoning makes any sense though...)

4 days ago he changed masks, which may also help (F&P Simplus mask in use now, ResMed AirFit F30i was old one, both full face).  I think the leak improvements are mostly due to being aware of the issue more than the actual mask itself.  Most of the improvement happened before he switched masks.

In the next week I am asking him to wear the "Eliminator Pillow" that I bought based on advice here.  We shall see it that helps.  I am going away for a week so I didn't want to make changes to the machine b/c I can't look at OSCAR for a week.  So good time for an intervention that does not require computer skills.

I wanted to share 3 images.  The first one shows the trend - which is definitely in the right direction.  Regarding the second and third images:  what is happening?  

3:42 to 3:53 as an example - weird vibratory "beats" phenomena on flow rate, respiratory rate spikes,  I notice leak rate > 0 prior to "beats" but drops to zero during beats.  Possibly it could be a positional thing, with chin tucked, then untucked for a little while, then revert?  

I don't know.  No events flagged here but it sure doesn't look normal to me.  This type of phenomenon happens at various times throughout a typical night for him.  I'd say more than half the time the patterns look sort of like this - not steady.  I think it is neurological rather than airway related, but I am totally just guessing.  

4:25 to 4:36 image: we see both obstructive apneas and clear airway apneas.  They look the same to me, so wondering how ResMed knows which is which?  Also SpO2 is not good during this time.

Dad reported he slept great this night.

Any thoughts on what the next step should be (after experimenting with the pillow, which starts tonight)?  

Thank you again.

PS - he had a sleep study last Friday. We have not heard any results yet. Obviously looking forward to see what they have to say.

[SonofBiPAPuser]

Hi everyone!  I am hoping for some advice.  

Since my last post, I found the soft cervical collar does not appear to make a large difference.  But I have him using it still. 

His AHI looks very good sometimes - last night it was 1.  It has averaged 2.5 over the last week.  But I think there are odd things as mentioned in my prior post that the machine does not characterize as issues.  I added an overview plot where I set the AHI scale from 0 to 30, so the change can be better seen.  His worst AHI was 76 on June 1, 2021.  

My father's respiration rate is high: median ~ 30/min., 95% ~ 45/min., peak = 50/min.  It never exceeds 50.00 - it flat lines there - I assume this is a machine setting of some sort?  His respiratory effort is weak

A few more questions - aside from previous post's questions:

1.  Last night I increased Trigger from high to very high.  I don't observe anything outside of normal variation based on one night's results.  I had set Trigger to high and Cycle to low back on 7/13 - but also changed the pressures on that day.  Note his AHI started improving on that day.  I thought it was the pressure change and less mask leaks, but maybe these settings are important for his improving results?  I don't know.  My idea is/was to increase the volume of the breath by keeping the machine at IPAP a little longer.  Is changing Trigger to very high logical?  

2.  Should I change Cycle from low to very low?

3.  My plan is to increase Ti Min to 0.7 seconds from the default 0.3 seconds.  I will break it into steps and set it at 0.5 seconds tonight.  Thoughts?  [Please see image from manual.]

4.  My thought is that Ti Max does nothing for him as it probably never comes into play.  So leaving it at the default 2.0 seconds for now.  Thoughts?

[Sleeprider]

Increasing TiMin sill hold IPAP for a longer time and avoid premature cycling to EPAP. With his very short median inspiration time, I think I would go straight to 0.7 and see if this causes any improvement in inspiration time and tidal volume. I assume you have not heard anything back on the sleep test yet.

It might be interesting to get a good closeup view of the respiration flow rate wave-form. We can sometimes interpret more from a 2-3 minute view that shows the inspiratory wave more clearly..

[SonofBiPAPuser]

Thank you, Sleeprider.

The sleep study was 2 weeks ago Thursday night - Friday morning.  Still no results.  I am shocked and frustrated; not clear why it should take so long.  The delay makes me question the quality of the recommendations that will come back but I will carefully review whatever I can get out of them to see.  Hopefully I will be in for a pleasant surprise.

I will move the Ti Min to 0.7 seconds directly, as per your suggestion.  But I think I will wait a few days, just to avoid confounding the results of the change I made yesterday (Trigger from high to 'very high.')  

I added 3 images of 3 minute duration from last night:

1.  An OA event.  This was the only one that occurred last night.
2.  A random example of what I think are good results.
3.  A time of unsteady results - that I think are bad.  These are frequent.  They do not get characterized as events by the ResMed machine.  I don't know if these are problematic?

If there is additional info I can provide, please let me know.  Thank you!

[SonofBiPAPuser]

Still no results from the sleep study.

4 days ago I changed Trigger from high to 'very high.'  I think that helped.  

Last night I used Ti Min = 0.7 sec as per the suggestion here.  It did not make any obvious change to the quality of the results.  I decided to push it a bit more tonight.

I observed the best / most steady sleep patterns had an inspiration time of 0.9 - 1.2 seconds and a respiration rate from 21-25 breaths/min.  In an effort to 'encourage' my father's breathing to synchronize in that range, I decided to set Ti Min / Ti Max = 0.8 sec / 1.4 sec for tonight.  And monitor results.

Attached is an image of what I think are good results, and also unsteady/bad results.  Any comments on these images, or the three I uploaded on my previous post, would be appreciated.

[SonofBiPAPuser]

Help please!  I got the results of the sleep study.  I have attached 1 file.  

(I have a 7 page report but I seem to have exceeded my allocated attachment usage.  So I deleted some of my older attachments and added just one page.  Should I crease a new thread?)  

I think the prescription is not going to help.  We'll try it tonight and find out.  But I am also wondering if I should be asking for more/different data from the hospital's sleep study center.  And I am wondering if I should find someone else to do a study (how do we find someone competent?) or if I should just ignore the sleep study Rx and do our own thing? 

I've had decent luck with these settings but still more work required.

13/8 cm H2O, Easy Breath = ON, TiMax= 2.0 sec, TiMin = 0.7 sec, Trigger = very high, Cycle = low --> AHI = 0.7
13/7 cm H2O, Easy Breath = OFF, TiMax= 1.3 sec, TiMin = 0.7 sec, Trigger = very high, Cycle = v. low, Rise Time = 600 msec --> AHI = 0.3

But there are still issues that I need help with on, as the breathing is quite unsteady. 

But anyway that help can wait for another day, since tonight we switch to the sleep study Rx of: 

19/9 cm H20, everything else default (Easy Breath = ON, TiMax = 2.0 sec, TiMin = 0.2 sec, Trigger = med, Cycle = med)

(Oxygen supplementation is always 4 L/min; so far this has not been varied)