New CPAP, new thread

[midwestguy]

Ha! Thanks, geer1, for giving all that history.

All the data before Feb.18 was on the A10 machine, 
and went with it in the exchange. My old sleep PA 
had the pressure at 8 to 11. 

I’m no longer playing Harry Homeowner. My 
son has most of my tools, and there’s no place 
to work if I had them. But I know a very good
woodworker who can make a nice wedge for 
under the mattress of my monster captain’s bed. 
I’ll contact him.

Tonight, pillows. Tomorrow, we’ll see. From 
8 to 8, huh?

Best,

Harv

[Geer1]

You only need to adjust the wedge if it is an issue. We are just spit balling ideas and don't have the information to know if it is actually an issue, only you know how your setup works and can decide if it needs to be adjusted or not. If the base of wedge is in your lower/mid back and you stay up high on it through the night then it probably isn't an issue. If you are sleeping at the base of the wedge or sliding down it in the night and the base of wedge is at your shoulders tilting head forward then that is not ideal. 

I believe the way a cervical collar and thin pillow help with positional apnea is by holding the chin forward and up similar to the head tilt chin lift technique used for opening an airway in first aid cases (just not as extreme). The attached image should give you an idea of what position keeps your airway the most open. Obviously you need to be comfortable so forcing yourself to sleep in that position is probably not the answer but it also shows why you want to avoid any chin tucking and be laying pretty much flat if not head tilted back slightly. The trick is to find the right pillows, collar etc that allow this to happen comfortably. 

If you need to try laying on flat portion of the bed first and then on your wedge to see how they compare and if you think the wedge is causing any issues.

[midwestguy]

Here are the statistics and last night's results. In bed at 9-ish, up at 7:30.
Nasal pillows, collar, wedge.

Am reconsidering chin strap. Will research. Any advice on those is welcome.

Thanks,

Harv

   

   

[Geer1]

Knightsbridge dual strap is the one that I see recommended the most, haven't tried one myself. Chin straps seem to work for some members but are probably the least effective way to stop leaks as they hold chin up but don't necessarily hold lips together. Some people still need to use mouth tape with one or end up switching to mouth tape. Main complaint seems to be the heat they add. If collar isn't keep your chin up then the chin strap might help that a bit, need to make sure the chin strap chosen pulls mostly up and not back as pulling back can worsen the positional apnea you have.

I assume you are hesitant to mouth tape in worries you won't be able to breath if necessary. There are some tapes made specifically for this application and Somnifix is the best known brand. The tape is just meant to hold lips together not fully seal and the Somnifix strips have a vent/opening you can breath through if necessary. Another option you could consider.

[midwestguy]

geer1,

Aha…. Thanks for pointing out the lips issue. Hadn’t thought about
lips staying open when strap lifts the chin. 

I’m not worried about not breathing through my mouth. But a drink
of water when I go to the bathroom would be nice.

Will check out surgical tapes, keeping your recommendation in mind.
Straps on hold, to see if collar plus tape can do the job.

You continue to be very helpful. Thanks, geer1.

Best,

Harv

[Geer1]

Tape or chin strap only really will help with the leaks, maybe a minor effect of helping keeping your chin in position. This last data you posted still shows some aspects of positional apnea/restriction even when leaks were not present.

Not sure how well you have picked up on reading flow rate charts but for example at 22:00 you can see how flow rate is fairly consistent and a decent amplitude indicating you are breathing well, this is what I would like your breathing to look like for most of the night.

At 23:20 you have a few positional apnea and then after that you don't have apnea but your flow rate is inconsistent and low amplitude due to some combination of restriction and mouth breathing (although doesn't look like you were too bad for leaks until after 3:00). The only way we can improve that is by positional treatments keeping airway open or higher pressures, pressures are usually less effective and create their own problems (like the higher leaks).

That all said this all comes down to how you are feeling. We aren't chasing perfect and I assume you keep asking questions because your sleep quality and tiredness are an issue. If you feel like you are getting decent enough treatment at any point let us know and just stick with it.

Your situation is very similar to my grandfathers. Like yourself he mouth breaths and leaks. He can't wear a collar because his neck is as thick as his head and the collar always slips up over his chin. Chin strap doesn't work for the same reason and made apnea worse by pulling chin back. FFM caused run away apnea like yours seems it might be doing. In his case he has high flow limitations that would max the pressure out, you don't have the same issue but similarly you do have near constant restriction of some sort (it just doesn't cause pressure to increase). In the end we locked his pressure in at a lower value and that seemed to give the most consistent results just by being the most comfortable for him even though he still has some restriction, apnea etc. He doesn't want to wear mouth tape so he puts up with the leaks, somehow he can sleep right through them so they bother grandma more than him. His results definitely aren't ideal but he deemed them good enough and not worth attempting to treat further. In the end you might need to do something similar and settle for what seems best to you, until then we can keep recommending things to try though.

[midwestguy]

Pulling back to take a little broader look:

Here's a review of my health issues as they apply to my sleep therapy. 

1. I have LPRD. Acid can back up into my esophagus.
I sleep on a bed wedge to reduce that.
No alternatives here. Wedge contributes to positional apnea.

2. A heart valve leak. Produces edema (swelling) in my legs.
I have a wedge under my legs, to reduce the edema. May
contribute to positional apnea.

3. Am a back sleeper. Habit acquired during old sleep therapy.

---

So?

Minimizing effects of positional apnea seems to be the top
priority.

* Will side-sleeping help?

* I'm using a collar now. What will tell me that it's working?

* Should taping be delayed until positional apnea is reduced?

As far as how I'm feeling? Pretty lousy. I'm never really awake
or alert. I have occasional headaches. I take meds for the
edema, for arthritis pain, and a blood thinner for a DVT.
I have fallen three times in the last two months with no major
injuries. [Insert thanks to the deity of your choice here.]

Started physical therapy to improve my leg strength, gait, and
balance. Want to get back in the gym.

Everything would improve if I got consistently better sleep.
I'm nowhere near that. Yawning at 9:30 AM is not a good sign.

Thanks, geer1.

Harv

[Geer1]

Wedge for reflux doesn't have to affect positional apnea as long as it is set up decently and depending on your arrangement of other pillows etc. Wedge for legs almost certainly does not affect positional apnea as it has no effect on your upper airway. As I tried to convey with the example of head tilt chin lift image positional apnea as we call it is just related to chin tucking or neck bending forward causing the upper airway to narrow. Collar and pillow choices are the main thing that will help hold your head in the correct position to avoid such chin tucking keeping your airway more open.

Side sleeping could potentially help but not necessarily. Again it comes down to the orientation of pillows, neck, head etc. If side sleeping is not comfortable as it isn't for many older individuals then trying to force yourself to sleep on side might cause more issues than not fully treating restricted breathing.

What you are looking for to know if positional treatments are working is what I explained earlier about your flow rate chart. You want to see few apnea and you want to see your flow rate chart look smooth and consistent, it shouldn't vary up and down or have extended periods where it looks shallow (all signs of restriction occurring).

If you haven't learned to interpret flow rate chart yet that might be one of the things you need to try and do so you are able to understand what a good night and poor night look like. These are some examples from your data.

Example 1: Good breathing (note the consistent breath shape and rounded peaks)

   

Example 2: Restricted breathing (flat topped and shallow, lower amplitude, low enough it isn't even causing pressure to increase to help you breath)

   

Example 3: Restricted breathing and exhalation (see how the exhale/negative portion of flow rate doesn't look normal, it drops down only momentarily and then is flat, likely you mouth breathing with palate closed)

   

[Geer1]

Example 4: Partial obstruction, likely positional in nature (you can see how breathing is very shallow then larger as your body tries harder to improve breathing this is likely due to positional partial obstruction but since it doesn't actually stop flow no apnea is flagged)

   

And here is the overall night showing each of these 4 examples. Hopefully you can see how the good breathings consistency and larger amplitude gives it a nice smooth look whereas all the other types of restrictions make flow rate inconsistent or shallow.

   

[midwestguy]

When you begin with the chart of the entire night, 
how do you pick out the places to expand and examine?

Thanks,

Harv