OSCAR Interpretation Help Please

[CPAPUser73]

Hi everyone,

Here are the most recent updates. The newest settings attempt (EPR OFF, MIN 9, MAX 9) unfortunately didn't help and instead caused a high AHI of almost 10.

Here are the screenshots.

           

Also as requested, I zoomed in for a ~ 7 min duration from the previous night to show the flurry of apneas around 6am. Images here: imgur.com/a/8RjX8QG

In terms of how he felt:
1. His previous settings have still felt the best so far. (EPR 2, MIN 12, MAX 20) - AHI around 5 or so on average.
2. 1st adjustments -  didn't notice too much change. (EPR 3, MIN 7, MAX 15) - AHI 7.76.
3. Second adjustments (EPR OFF, MIN 9, MAX 9) - slept worst - felt different due to lack of pressure. - AHI 9.94


Any suggestions or recommendations are greatly appreciated!

[SarcasticDave94]

Here's the thought process I'd use: answer the questions for yourself to know what action to take.

In light of the pressure and EPR edits, has the therapy become uncomfortable?

Has the high concentration of Central Apnea made therapy worse?

An exercise for you: out of a 7 day week, how many are good versus bad nights on therapy? How many nights have some sort of bad CA like this one?

My reasoning for asking is to determine what is trending with the CA regardless of edits. If it's trending bad CA despite edits, taking up the fight for ASV is really the best answer.

Me personally, with just the info already here it's likely that the CA aren't responding positively to the edits already made, and they probably won't with more edits. CA tend to respond fairly quickly to edits that will reduce them. If not in a day or so, they likely won't given more time. I think the ASV is considered necessary to eliminate/treat the CA and allow normal, comfortable therapy settings at the same time.

[Sleeprider]

CPAPuser73, we really need to see a closeup zoom of the flow rate. The Organize Your Oscar Charts wiki in my signature describes the procedure for a zoomed image. Your dad appears to have a pretty severe inspiratory flow limitation that is not being captured by the the statistics because it is so persistent. I really thing you need to get back to EPR at 3 to help with inspiratory effort. I don't anticipate that the CA events will get worse with the EPR, but we can watch for that. Your records indicate he did best with EPR 2.but flow limits were clearly best at EPR 3 and the AHI was not significantly greater. The minimum pressure of 12 seemed to work well, and I think a maximum pressure of 14 should be sufficient for any obstruction we see, and we want to avoid higher pressure to avoid triggering the CA. It's possible your dad would do really well with ASV. It would treat both obstructive and central aspects of his breathing disorder and would level out the minute vent. There is some positional obstructive apnea in some of the charts, so be sure he is not sleeping on multiple pillows or one that is too firm.

Before we commit to anything, let's look at some zooms of the flow rate at a 3-4 minute zoom level. Hint: on the Events Tab there is a zoom slider at the bottom.

[SarcasticDave94]

FWIW EPR back to 3 will probably give similar results to the beginning of the thread. If accurate, it's not a runaway bad CA but not treated either.

The actions Sleeprider suggests will be helpful in demonstrating you've exhausted all edits possible.

[Geer1]

Yeah lets try what Sleeprider suggested, 12-14 cm with EPR of 3. There were some positive signs in that 3 EPR data and it might have just been a bad night, the 12 cm min pressure will make it more directly comparable to original EPR of 2 data.

That zoom you showed shows what I believe were a few mixed apnea (central apnea during which an obstruction forms, were flagged as obstructive) and then central apnea. The central apnea appear idiopathic in nature and not CO2 driven (which is the type lower EPR can sometimes help), unfortunately this machine cannot treat central apnea and ASV may be required/recommended. Turning EPR off resulted in high AHI both times and my guess is that it is because it makes it more difficult for him to breath out, flow limitations and his comments support that it wasn't comfortable to him so I would stick with EPR of 2 or more. The best we can do with this machine is try to find comfortable, easy breathing settings will hopefully reduce the apnea and EPR 3 is the best chance of that.

Do you have a copy of his sleep study? If so should post a redacted version (remove any personal information).

[CPAPUser73]

Thank you all for the excellent feedback! I truly appreciate it! My dad will try the settings that sleeprider suggested tonight and I will report back with how things go. I will also work on posting the closeup zoom of the flow rate as well. 

Thank you for the suggestion regarding the pillows as well! Come to find out, he was indeed sleeping with 3+ pillows so tonight he will try using just one good pillow instead.

[CPAPUser73]

CPAPuser73, we really need to see a closeup zoom  of the flow rate. The Organize Your Oscar Charts wiki in my signature describes the procedure for a zoomed image. Your dad appears to have a pretty severe inspiratory flow limitation that is not being captured by the the statistics because it is so persistent.  I really thing you need to get back to EPR at 3 to help with inspiratory effort.  I don't anticipate that the CA events will get worse with the EPR, but we can watch for that. Your records indicate he did best with EPR 2.but flow limits were clearly best at EPR 3 and the AHI was not significantly greater.  The minimum pressure of 12 seemed to work well, and I think a maximum pressure of 14 should be sufficient for any obstruction we see, and we want to avoid higher pressure to avoid triggering the CA.  It's possible your dad would do really well with ASV.  It would treat both obstructive and central aspects of his breathing disorder and would level out the minute vent.  There is some positional obstructive apnea in some of the charts, so be sure he is not sleeping on multiple pillows or one that is too firm.

Before we commit to anything, let's look at some zooms of the flow rate at a 3-4 minute zoom level.  Hint: on the Events Tab there is a zoom slider at the bottom.

Okay, here is the latest update. With those settings he had an AHI of 6.22. So moving in the right direction, but slightly higher than his typical AHI with the original settings. He plans on trying the new settings again tonight as well to see how things go and has stopped using multiple pillows. 

           

Let me know if you recommend any tweaking to the settings. Any idea why he tends to have the most apnea episodes closer to the end of his sleep around 5 AM?

And here is the link to view the zoomed in 3 minute views of the flow rate: https://imgur.com/a/Q0J81td

As always, thank you all for your continued help with this. My dad and I truly appreciate it. 

Let me know if you have any suggestions.

[Geer1]

Lets try another night like this.

Having episodes near the end of sleep could indicate a potential correlation with rem sleep. Central apnea occurs rarely in rem sleep but obstruction is worse. The first images you posted looked like idiopathic centrals, these recent ones I am not 100% sure of as they don't have a typical central or obstruction look (kind of an inbetween).

[CPAPUser73]

Here are the latest readings from last night with the same settings. AHI of 7 so it seems his original settings are still best. 

           

[Sleeprider]

In the first chart we see chronic flow limitation. The segment at 05:13:15 shows increasing flow limitation ending in arousal and recovery breathing which transitions to a feedback loop of centrals that lasts to almost 06:00.  I don't see obstructive apnea where they are flagged.  My thought on this is that this type of CA feedback loop may be susceptible to treatment with EERS.  You have a high sensitivity to changes in your CO2 as shown by how this sequence was startled, and it just keeps feeding itself with hyperventilation hypercapnea leading to hypocapnic suppressed breathing and the process repeats and repeats.  The alternatives to EERS is avoiding the hyperventilation caused by flow limit related RERA, or ASV intervention.  You actually do better with higher EPR because it avoids the initial RERA, but you are right on the edge of the feedback look anytime things get out of balance.