My dad's first full night data, is it concerning? (many CAs)

[EveryBreatheUTake]

Hi All, This is my dad's first time using CPAP (resmed airsense 10). The first complete day of data is attached.

Some basic information about him: in his 60s, in-lab sleep study reports an AHI of 32.1 (all obstructive, no central). My questions are:

1. Is it normal to see such frequent Clear Airway events for new users? Sleep study suggests no central apnea. I learned from this forum that there is a thing called "treatment-emergent central sleep apnea", not sure if this is the case?

2. The current pressure setting is Min 6, Max 20 with EPR 2. How should I adjust the settings? It seems 6 is too low as most of the time the pressure is above 7? Also is there any benefits if I town down the Max pressure?

3. From the report, the AHI was down to 4.3, I'd say CPAP is actually helping him sleep? However there were occasional leaks which waked him up a few times in the night. Any suggestions based on these charts would be greatly appreciated!

Thank you
Stan

[Expat31]

Hi, 

At first glance, I have the following initial observations :-

 1. As a starting point, I would increase minimum pressure to 8, and EPR to 3, to see where this goes. It may not be enough, as your father has sleep apnea classified as "severe". 

  2. I see a likely issue of positional apnea, indicated by the clustering of events just before 4pm. 
Do you have the breakdown of AHI from the sleep study, between each sleeping position, was supine dominant? 
This video may be of some interest - sleeping positions & pillow adjustments (video Mayo)

  3. Leaking, reading the mask primer may help, for good mask fitting. For mouth leaking with a nasal or pillows mask, a chin strap or mouth tape can be efficient. 

  4. Regarding central apneas, these often occur in the early stages of therapy.  Getting used to this new therapy environment takes a little time, and usually disappear, especially when the basic settings are optimised,

[EveryBreatheUTake]

Hi Expat31, Thanks for the analysis! I adjusted settings according to your suggestion.

Re 2: Yes, his AHI is indeed supine dominant! But I thought it should led to OA events, which CPAP should help - and the clustering of events are all CAs instead of OAs. Could the positional apnea also cause CAs?

Re 3: He used mouth tape. The leak was mainly from the nasal mask leaking when he changed positions. Maybe he can add more pillows to have a more stable sleeping position.

- Stan

[Expat31]

Hi, 

Clustering is well known to provoke apnea events. They can be either obstructive or "centrals" the latter are usually false positives. These "clumps" sort of "meld" into almost one large continuous event, which can be quite unpleasant. 

CPAP pressure alone cannot exert sufficient pressure to untangle all this, so as to ropen the airways.

There are two main causes for positional apnea events. 

1) The trachea gets crimped or kinked out of alignment, either partially or fully, impeding the flow of air to the lungs. This is often caused by the chin dropping towards the chest. This issue can be usually be resolved by three principal methods:-
    - Using a soft cervical collar to straighten out the airflow path. 
    - Slimmer pillow to keep the head further back. 
    - Or simply side sleeping. 

2)  During  REM sleep, when the body becomes semi paralysed and muscle tone is lost, the tongue can fall back against the pharynx wall, blocking the airway. Again the solution can be resolved by avoiding sleeping supine. 

For a pretty clear visual demonstration  of the potential negative effects of the supine position, see this supine positional apnea (video).

The leak spikes in the first graph could indicate mask displacement due to change in sleep position. However if dry mouth is experienced, this could rather indicate mouth leakage.

[EveryBreatheUTake]

That's very insightful! We will try a slimer pillow and see if the tennis trick would help him sleep on the side.

Thanks again,
Stan