Help me in understanding my dad's sleep data (OSCAR)

[xnani]

Hello,

My dad(69) underwent a Angioplasty(2 stents) recently and the cardiologist suggested to go for sleep study.

Here is what pulmonologist suggested the settings:
   

Here in India, we have to buy the device as the insurance doesn't cover the device cost. So, i got the "ResMed Aircurve 10 VAuto" (with a Full face mask F20) on rental for a month. 

We started using the device from 29th July. I have uploaded the screenshots of these sleep data and along with the sleep study report here on google drive (drive.google.com/drive/folders/1a4svIiNgamLxAJTNykvLMxj-D_B1Ih5P). 


I have few queries after going through these data:
* Doctor only mentioned about having severe obstructive sleep apnea but in the daily report, it says "Clear Airway(CA)" ? Does he also have Central sleep apnea ?
* Are the settings fine? do i need to change anything ?
* We can use this device till the end of this month. Should i buy the same device or do i need to get Lumis 100 VPAP ST ?
* any other suggestions are welcome  

Dad's medical history:
Currently he is on blood thinners and cholesterol control medicines along with Diabetic, hypertension and vitamin(VITAMIN C+ELEMENTAL IRON+FOLIC ACID+VITAMIN B12) medicine.

[gainerfull]

Is there a reason you decided to rent the Aircurve S? Your dad needs more inspiratory minimum pressure to control the obstructive events but I don't know bipap well enough to recommend precise settings. Perhaps another more knowledgeable member will chime in. Yes, CA - clear airway is central apnea. If you can get ahold of one I'd recommend the Resmed Airsense 10 vauto or the Resmed Airsense 11 vauto for the next month.

[xnani]

I'd recommend the Resmed Airsense 10 vauto 

Isn't Airsense a cpap? 
Doctor mentioned that my dad needs bipap with manual IPAP 22 and EPAP 12 settings. 

So I enquired about bipap with official ResMed.co.in India and one of their Sleep Couch suggested AirCurve 10 auto and Lumis 100 VPAP ST.
She said Lumis 100 has more advanced features but as doctor mentioned about S mode so I went for AirCurve 10 VAuto. Both cost same price (~ INR 70,000).

[Gideon]

Post your sleep report here. It is in this case very important to understand what has happened, and a brief you related to me ( beerdujour) on Reddit. That timing is also important.

Brief synopsis: serious heart and lung issues occurring in the same timeframe as the split sleep study. This titration study showed a window of good treatment with the best oxygenation star[ing at these high pressures. Per the titration the 12/22 in "S" mode started that window. On that night this was the best for him.

Once his lungs are clear and he 8s recovered from surgery I'd suggest a reevaluation of his treatment.

I'd still get a recording oximeter even if you need to get it shipped in.

I strongly believe that once your dad is recovered that his base apnea will be significantly lower and we will be all supported with less pressure and pressure support.

[Sleeprider]

My comments are for the Oscar chart posted above. The obstructive sleep apnea index is less than one per hour and appears controlled with the EPAP 12 pressure. The 10 cm pressure support being used is unusually high and may contribute to the CA event rate. The OA events occur in brief clusters which may suggest a positional obstruction, such as a high pillow or head/neck position is occasionally contributing to obstruction. We have found that CA events can oftehin be mitigated by changing the trigger sensitivity settings to high or very-high. I recommend changing trigger sensitivity to high and observing results. Other observations are that your father's respiration rate of 20 is relatively high with a very short inspiration time, however the inspiration and expiration time ratio is normal at 1:2. Tidal volume is appropriate for man of smaller stature and minute vent is relatively high due to high respiration rate. I don't see anything in the respiratory statistics that are significant to his therapy.

Here is a link to our positional apnea article for your consideration, and I think you may see improvement in the CA event rate by changing the trigger sensitivity to high. Be aware some Vauto units sold in Europe and perhaps Asia do not have the trigger settings available, so don't be too surprised if it is not there. https://www.apneaboard.com/wiki/index.ph...onal_Apnea

[xnani]

Ok, so here is the medical History of my dad for future reference. Also i'll be using this thread to post all future queries.

TLDR (per discharge summary):
- ADHF
- HYPERTENSIVE EMERGENCY
- CRITICAL AND DIFFUSE LAD DISEASE
- S/P ANGIOPLASTY WITH 2 STENTS(VIVO ISAR 2.5X32 IN MID TO DISTAL LAD, VIVO ISAR 3X32 FROM OSTIAL TO MID LAD)
- Obstructive sleep apnea
- Diabetes mellitus
- Hypertension 
- Old CVA x10yrs
- Umbilical hernia
- Morbid obesity.

Brief:

* On July 06, Rushed to Emergency because of breathing difficulty ( SPO2 was between 75 - 80)

* On July 07, After diagnosis, treated for fluid in lungs and Heart Attack (coronary angiogram, angioplasty 2 STENTS)

* On July 10, Went for sleep study - on this day he was still getting treated for fluid in lungs - they were giving him neutralizer medicines for 3 times a day.

* On July 19, Pulmonologist consultation, After looking at the sleep study report, she said My dad has Severe OSA ( AHI - 107, REM AHI - 123) and Advised BPAP - S with full face mask, IPAP 22, EPAP - 12

* I'll update his health status on 17th of August as we have a monthly followup with Cardiologist, Pulmonologist, Nephrologist and Endocrinologist.

For now, he is doing very well and we are continuing with the Sleep therapy with the said IPAP EPAP settings.

[xnani]

I'd suggest a reevaluation of his treatment.

I'd still get a recording oximeter even if you need to get it shipped in.  

@Gideon - I totally agree that he needs a reevaluation, I'll speak with the pulmonologist regarding this. And yes, I'm getting recorded oxymeter shipped. I'll get it in 10-15 Days.

The OA events occur in brief clusters which may suggest a positional obstruction, such as a high pillow or head/neck position is occasionally contributing to obstruction.  We have found that CA events can oftehin be mitigated by changing the trigger sensitivity settings to high or very-high.  I recommend changing trigger sensitivity to high and observing results.  

@Sleeprider You are correct, he uses two pillows(wakefit.co/pillows-and-cushions/sleeping-pillow/WSPS). I asked him to use only one from today.


Also, I wanted to test out VPAPAuto mode. So i set the mode to VPAPAuto with Min EPAP: 8 and MAX IPAP: 22 and left the remaining settings as is.
In the morning, My dad said, this is feeling much better instead of those fixed settings. and i monitored his spo2 levels manually till 2am. Haven't seen it go below 95.

Please review the attached report and let me know if i need to change anything.

[Sleeprider]

In VPAP S mode your dad was using PS 10 (22/12), and your settings with Vauto have reduced that to PS 4, and reduced pressure to a median 12.3/8.3 with 95% pressure at 16.3/12.3. This results is a lower tidal volume and minute vent and higher respiration rate over 23 bpm, and also represents a lower "positive end expiratory pressure" (PEEP), which may affect oxygenation. The higher respiration rate may suggest a higher CO2 retention, and perhaps lower SpO2. Aside from reduced ventilation rates, the results look good with no apnea or hypopnea events and low flow limitation. I'm certain this is more comfortable. Without a recording pulse oximeter, we can't know if this has affected his oxygen saturation. Given the very good efficacy of these settings, if SpO2 is adversely affected, it may be advisable to supplement oxygen, rather than force the high pressure support to hyperventilate his lungs. That is a doctor's decision to make and something to discuss at the next appointment. I think it may be advisable to increase pressure support with the Vauto settings and increase the level of respiratory assistance from the device to move tidal volume above 300 mL. This should in theory assist with CO2 expiration, but there is no way to know if that is an issue without SpO2 data. I am uncomfortable advising on settings that are radically different from what your doctor recommended in an elderly patient with complications shown by the information you posted earlier. I hope you will arrange a discussion with the doctor as soon as possible to relate the greater comfort of your revised settings, but concerns for how this may affect ventilation and oxygen. This should be able to be monitored in a home setting using a pulse oximeter or holter monitor. There is just an awful lot to unpack here, and it is probable your dad's titration test included 12/8 pressure ps-4 and it was rejected for a reason.

[Gideon]

FYI Sleeprider is one of the best at this.

I too an reluctant to radically change his settings from what was prescribed, especially in this case.  The increased comfort is a significant talking points.  And the overnight oxygen readings are so very, very important in this case. IMHO little to nothing should be adjusted without this data by anyone, doctor included.

[xnani]

Hello, 

I finally got the contec CMS 50E  device and have used it for the last few days. 
I'm attaching the last 2 days screenshot with prescribed settings (22/12) and spo2 data included.

We have the Doctors(Pulmonologitst) appointment tomorrow and i'll ask about high resp rate and low tidal volume. Apart from this pls let me know i need to mention anything else to the doctor.