Help with optimizing PAP for 85-year-old

[QuestionableQuerant]

Hello,

I'm writing on behalf of my 85-year-old father, who was among those affected by the Philips recall. Before switching to a new device, he used a DreamStation from 11/22/18 thru 7/1/21 to mixed results, enjoying his best average daily AHI (7.04) during its final 24 days of use, immediately following setting adjustments applied by his sleep doc (pressure 8-12, A-Flex = 2). The attached table shows his average event indexes over 2.5+ years in various modes at various settings, from most recent to least.

Since he began using a ResMed AirSense Autoset 10 on July 2, his clear airway events have increased to an average of over 5.8 her hour. Even when his numbers don’t look terrible, his sleep is seldom restorative. A few general observations re: how various settings tried for that device affect his events:

EPR

Strong inverse relationship between EPR and hypopneas.

• Hypopneas run rampant when EPR is off.
  
• Needs EPR set to at least 2 to consistently limit.
  
• EPR setting of 3 even more effective than 2 for limiting hypopneas, but generally at the cost of a (further) increase in CAs.
  

Weaker direct relationship between EPR and CAs.

• Not always predictable, but an increase in EPR usually correlates with a noticeable spike in CAs (often w/clusterings of events).
  
• Even at fixed pressures, turning off EPR at best serves not to exacerbate still persistent CA events – but allows hypopneas to proliferate.
  
• Generally little correlation between EPR setting and OAs.
  

Pressure

Fixed pressures have returned generally lousy results for him (as was the case w/the DreamStation).

• Fixed pressure of 9 or 11 with EPR off caused hypopneas to increase; CAs averaged 5.3+ per hour at either setting.
  
• Fixed pressure of 11 with EPR = 3 limited hypopneas to well under 1 per hour but caused CAs to increase to over 11 per hour.
  
• Fixed pressure of 8.6 with EPR = 3 limited hypopneas to well under 1 per hour; CAs averaged over 5 per hour.
  
• Fixed pressure of 7.6 w/EPR = 2 less effective for controlling hypopneas (~2 per hour); CAs averaged over 10 per hour.
  

 

His numbers in APAP mode are still suboptimal.

• We started using the device with a pressure setting of between 8 and 15.
  
• I hoped to use the resulting data to work toward a fixed pressure – or, at the very least, a narrower pressure range sufficient to keep his airway open while avoiding CAs to the greatest extent possible.
  
• For a (brief) period, I thought a pressure range of between 8 and 11, response mode of “soft”, and EPR enabled full-time and set to 2 produced results sufficient to tide him over until his therapy could be more properly optimized.
  
• These settings roughly match those of his former DreamStation when last used (pressure 8 – 12, A-Flex = 2).
  
• He had a couple of relatively good nights at those settings, at least from a numbers standpoint.
  
• However, his results have gradually worsened, with double-digit AHIs the past two nights (due mostly to CAs).
  

     

[As an aside, I’ve seen firsthand how ResMed’s APAP employs an algorithm different from that used by Philips’s counterpart. In his particular case:

• The DreamStation, with a pressure range of 8 – 12 and A-Flex = 2, attempted to maintain a pressure of 8 for as long as possible, spiking upward only when needed and for just long enough to manage his hypopneas or obstructive events.
  
• In contrast, the Autoset at roughly comparable settings (pressure set to 8 – 12, Autoset Response = soft, EPR = 2) seemed to want to maintain a pressure of at least 9+ (often 10+) over an extended period, which is why I lowered the upper limit from 12 to 11, to see if I could entice the Autoset to behave a bit more like the DreamStation (no dice).]
  

Whether EPR is on or off in APAP mode, his CAs still persist.

• In APAP mode with EPR off, CAs generally range between 3 and 6.5 per hour (hypopneas at setting range from 3.5 to 6.5 per hour).
  
• In APAP mode with EPR set to 2, CAs generally range between 4 and 7 per hour, sometimes slightly lower, at other times exceeding 10 per hour.
  

Thank you for reading this far. I do have some questions:

• Would it help if I were to provide representative OSCAR screenshots of relevant data at various settings?
  
• Based upon what I’ve written, do you think he might qualify to be prescribed an ASV, which I suspect is what he really needs after 2.5+ years of APAP/CPAP? If so, any tips re: how I could persuade his sleep doc to do so? I’m concerned that might not be so easy, as the doc felt a second sleep study “wouldn’t be helpful at this time” (a titration was done last Nov). He’s scheduled to see the doc in roughly 6 weeks.
  
• If the doc nixes ASV, might EERS be an option? If so, whom could I contact for assistance, as the doc seemed less than enthusiastic over boosting available CO2 in general (with reason, I’m sure) and I lack the mechanical or engineering acumen to try this myself?
  
• Any thoughts on how I could try to optimize his current device’s settings to make the best of what he now has?
  

Thank you again for reading and for any insight you might be able to lend – apologies for the length.

[Sleeprider]

Your observations of an inverse relationship between hypopnea and EPR, and a correlation of EPR to CA events is very common. Interesting trends from your table are that obstructive apnea are correlated to pressure. This is unusual in that obstructive events are normally improved with increasing pressure. I suspect there may be some COPD at work here, and some health background would be helpful. The chart that will help us most is the Daily Details with the left sidebar that shows respiratory statistics and settings. Instructions for that graph are in my signature links (organizing you Oscar charts). There are a couple things we can do to improve therapy, but I'd like to take a look at the daily details before getting ahead of myself.

[QuestionableQuerant]

Thanks, SleepRider. It's interesting that turning off A-Flex in DreamStation correlated with my father's experiencing a substantially higher number of events identified as OAs. I wonder whether events categorized by DreamStation as OAs might be classified as hypopneas by ResMed units; if so, the inverse relationship btwn EPR and hypopneas might be roughly analogous to that of DreamStation's A-Flex and (a particular subset of) OAs.

My father has no known history or diagnosis of any chronic respiratory issues. However, he did suffer a hemorrhagic stroke a little over three years ago in the area of his right parietal lobe; the neurologist who's treated him since is also overseeing his sleep therapy. While he made a strong physical recovery from the stroke, he began to experience new (though relatively mild) issues with attention, concentration, and memory that, over recent months, have become more pronounced and gradually have caused him to require a bit more guidance with managing his day-to-day activities. Daily meds: he takes an ACE2 inhibitor + diuretic, a statin drug (which, I understand, can affect OSA), a multivitamin, a fish oil supplement (DHA), and a stool softener.

While I understand that effective sleep therapy isn't a panacea for his issues, I believe that optimized therapy facilitating restorative sleep absolutely could help him to both enjoy a better quality of life and get the most out of his remaining abilities.

I've attached three hopefully representative screenshots of nights where leaks weren't a major confounding factor:, one of a "good" night using pressure of 8-11 (no ramp), EPR = 2, and "soft" response mode; another where the same settings were used but to a much worse result; and a third showing a really bad outcome to an attempt to using a fixed pressure setting (of 9) with EPR off. (I had to use my laptop's native screenshot capability as OSCAR's seemingly wanted to save an image of only a very small part of the application area displayed on screen.)

Please let me know if you'd like to see additional screenshots showing flow rates over particular periods, or of anything else for that matter. Thank you again for your help and time.

[Sleeprider]

How is your dad's heart health? Does he have any heart failure or left ventricular ejection fraction less than 45%? If he doesn't have those risk factors, I'd really like to see his doctor order an ASV titration. The adaptive servo ventilator, evens out breathing volume and rate and directly treats hypopnea and central apnea. His apnea profile is one that usually benefits from ASV and results in consistently less than 2 AHI. It is obviously a more expensive bilevel machine, but it allows the user to use their natural breathing pace and volume, learns that rate and minute vent (L/min) and helps to maintain it with pressure support when, and if needed. So it stays out of the way until you need it, then helps to maintain respiration. CPAP is not the ideal solution for what we're seeing here, but it is always the first step. Based on the AHI results with CPAP, it is failing to provide the efficacy we expect from the therapy, so we know the problem(s) are not purely obstructive. The lack of correlation between pressure and obstruction are one clue, but there are many others.

[QuestionableQuerant]

Fortunately, my father has no known heart issues or diagnosis.

When I last corresponded with his sleep doc's office a few weeks back, he replied that he didn't see the need for a 2nd sleep study "at this time" and suggested that we continue w/the 8-15 pressure setting we had been using. Any suggestions on how we (I) could approach the doctor during our next appointment to persuade him of the virtue of scheduling an ASV titration? If the doc proves particularly obdurate, do you think EERS might be worth considering? I really hope we don't have to go doctor (neurologist) shopping because I like and respect his current one as a caring and competent practitioner. But, if we have to...

Also...anything come to mind that we could try that might improve the quality of his sleep using his current equipment while we're pursuing a better solution? I've tried pretty much everything within reason that I could think to over the past month (more tinkering that I was comfortable with, tbh) - w/o any real sustained success. After 4 subpar nights of 8-11, EPR = 2, I'm tempted to try using a fixed pressure of 9ish w/EPR = 2...but w/o a high degree of confidence in a good outcome. The 7ish average AHI he scored from his final 24 days of using the DreamStation is looking comparatively good right now (still subpar, but not egregiously so).

Thank you again.

[Sleeprider]

I’m impressed you are aware of EERS! It can be a great way to reduce central events and periodic breathing. We have not looked closely emoter the respiratory flow rate in this case to say whether EERS might be viable, but glad to do so. I just have a feeling ASV might be a faster more positive solution. Let’s go ahead and take a look at the respiratory pattern that leads into clusters of events and see what that has to offer to our insights. 2-3 minute closeup of the respiration flow leading into CA or H events.

[QuestionableQuerant]

My strong preference would be for his sleep doc to refer him for an ASV titration, after which he'd (I hope) prescribe an ASV. I thought that EERS might offer a good fallback should we encounter difficulty persuading him - or another doctor - to do so.

Whatever I know about EERS is largely owed to my having read an entry in apneaboard's wiki. From what I could gather, 1) the goal is to modify the mask and tubing so that there always remains just enough residual CO2 to maintain the respiratory drive and 2) I rather doubt I have the mechanical and engineering acumen to safely and effectively so modify his equipment myself (I'd feel more comfortable giving it a go were I doing so for myself).

I've attached hopefully representative snippets of flow rates leading up to and during CA clusters occurring during the two previously referenced "bad" outcome nights.

Thanks again for taking the time...

[SarcasticDave94]

I see ASV as being a good choice. 1. there's consistently inconsistent CA that of this level can't be avoided enough with this current PAP, seems proven with the OSCAR charts, 2. I'm thinking these same CA were present with the DreamStation but not as aggravated, there's the consistent high AHI on record. 3. You've attempted to avoid CA as best as you can, the tools just aren't there with this PAP, but it's really not going well. Time to treat instead of avoid.

[QuestionableQuerant]

Thank you both for your replies and input.

I've prepared a letter directed to his sleep doc, which summarizes much of the content of this thread to support my request that my father be referred for an ASV titratrion.

While it's a bit long, if anyone could read thru it when time permits and offer suggestions and feedback re: content or tone, I'd greatly appreciate it (I really need to get this right).

*******
Dear Dr. ______,

I’m writing to provide an update since last corresponding with your office a few weeks ago – and to ask whether you’d be willing to consider referring my father for an ASV titration in response.

His average daily clear airway events now exceed 6.2 per hour since switching to the ResMed AirSense 10 Autoset (July 2 – Aug 13). This has caused me to wonder if his new ResMed device might be venting expired air (and residual CO2) more efficiently than his former DreamStation, and if that could be contributing to an increase in his CAs.

Even on those occasions when his numbers don’t look downright concerning, his sleep since has seldom been restorative. Below are some observations re: how various settings tried on his new device affected his events and sleep. [I succumbed to the temptation to tinker in response to both the data, which I found particularly jarring after the (comparatively) better results achieved during his final period of using the DreamStation, and seeing my father often appear even less alert and well-rested than he had previously.]

EPR

* Strong inverse relationship between EPR and hypopneas.

• Hypopneas increase when EPR is off, whether using fixed or variable pressure (averaging 4.7 per hr) – tendency may be even more pronounced at fixed pressures.
  
• Needs EPR set to at least 2 to consistently control.
  
• EPR setting of 3 even more effective than 2 for limiting hypopneas, but often at the cost of a (further) increase in CAs.
  

* Weaker direct relationship between EPR and CAs.

• Not always predictable, but an increase in EPR usually correlates with a noticeable spike in CAs (often w/clusterings of events).
  
• Even at fixed pressures, turning off EPR seems – at best – to have the effect of not exacerbating still persistent CA events – while allowing hypopneas to proliferate.
  

* Generally little correlation between EPR setting and OAs.

Pressure (APAP)

* In APAP mode, whether EPR is on or off, his CAs still persist.

• With EPR off, his CAs averaged between 3.6 and 6.3 per hour (but his hypopneas in APAP mode w/EPR off averaged between 2.3 to 6.5 per hour).
  
• With EPR set to 2, his CAs average between 3.6 and 11 per hour.
  

* Kept original pressure setting of 8 – 12 (same as the final setting of his DreamStation) during his first two days of using the device. Later increased the max to 15, as the device seemed to want to consistently keep pressure at or near the prior max of 12.

* My hope then (since disappointed) was to use the resulting data over subsequent days and weeks to work toward a (low as possible) fixed pressure – or, at the very least, a narrower and lower pressure range sufficient to keep his airway open while avoiding CAs to the greatest extent possible...with EPR sufficient to limit hypopneas w/o exacerbating CAs.

* For a (brief) period, I had hoped a pressure range of between 8 and 11, response mode of “soft”, and EPR enabled full-time and set to 2 might produce results sufficient to tide him over until his therapy could be more professionally optimized.

• These settings roughly match those of his former DreamStation when last used (pressure 8 – 12, A-Flex = 2).
  
• He experienced a few relatively “good” nights at those settings (AHI below 8), at least from a numbers standpoint.
  
• However, at the same settings, he experienced double-digit AHIs twice in the past week (due mostly to CAs, which averaged 11 and 9.5, respectively).
  

Pressure (CPAP)

* Attempted using fixed pressures w/his new device in a bid to avoid CAs but received generally lousy results overall (as was the case w/the DreamStation when fixed pressures were tried).

* Fixed pressure of 9 or 11 with EPR off: hypopneas averaged 5.3 to 6.5 per hour; interestingly, CAs also averaged between 5.3 and 7.7 per hour. Thus, it seems that using a fixed pressure with EPR off both correlated w/increase in hypopneas and provided little benefit w/r/t limiting CAs.

* Fixed pressure of 11 with EPR = 3 limited hypopneas to .66 per hour but caused CAs to increase to over 11 per hour.

* Fixed pressure of 8.6 with EPR = 3 limited hypopneas to .7 per hour; CAs averaged 5.9 per hour.

* Fixed pressure of 7.6 w/EPR = 2 less effective for controlling hypopneas (~2 per hour); CAs averaged over 10 per hour.

To lend a visual perspective, I’ve attached screenshots of data for three representative nights of therapy: respective “good” and “bad” nights with pressure range set to 8-11 and EPR set to 2, and a ghastly night with pressure fixed at 9 and EPR turned off. Attached as well are images of the waveforms associated with two selected clear airway clusters and of the respiration flows that preceded them.

I’m requesting that my father be referred for an ASV titration for the following reasons:

* He’s given APAP/CPAP every opportunity to succeed since starting therapy Nov 2018.

• Over 2.5 years of using the DreamStation, his best average AHI (7.05) was achieved during his final 24 days of use.
  
• Over 951 days of using the DreamStation and across various attempted settings, his average AHI was 8.58; his average RERAs over the same period were 1.36 per hour.
  
• He’s been fully compliant since starting sleep therapy Nov 2018, even going so far as to purchase out of pocket a new APAP machine after the Philips recall so he could safely continue.
  
• The results of PAP therapy with his current device have been less than reassuring.
  

* I don’t see a path for optimizing his current PAP therapy to the extent that it would regularly and reliably enable him to achieve proper respiration during sleep:

• He needs EPR enabled in order to limit hypopneas – but an increase in EPR tends to exacerbate his issues with CAs.
  
• His CAs persist even when EPR is turned off; further, disabling EPR causes his hypopneas to increase.
  
• Lower pressures have proven to be no panacea for his seemingly ineluctable issue with CAs.
  

Please let me know your thoughts.

Respectfully,

[SarcasticDave94]

Just my opinion, doc may not get much about EPR. After all it's marketed as a comfort tool not therapy.

Myself, I'd make the request shorter and direct. Focus on a few negatives, CA, not well rested, uncomfortable. FWIW there's no positives but all negatives that need be mentioned.

You're concerned over the high amount of CA. Maybe you're learning about CA and see that this could be the issue. You could try introducing OSCAR data, as this is where you see CA, but reserve it as an option.

Better is if there's been any sleep study you'll get a copy. HIPAA law permits this. You can post redacted version for us to view. We see this & that, and there could be CA activity there. You want to find CA on the doctor's accepted chart.

Now you have doctor accepted data that notes CA. You'll suggest doctor considers helping by getting dad in to take a titration including ASV as you've read ASV is the machine designed specific to treat CA.

Something like that is my edited version opinion.