Oxygen levels below 90% for 7% of night and below 94% for 34% inspite of Bipap

[bhavintu79]

Hi Friends

I was diagnosed with Sleep Apnea on a Sleep study several years ago. I started using an Aircurve 10 VAuto and am perplexed with my results below. Any guidance and responses to questions from others with know-how would be appreciated -

* I use Get Wellue ring every night to track my oxygen levels

* I use Aircurve 10 VAuto in VAuto mode with PS 4, and default settings, and a nasal mask

* With or without the Bipap my oxygen level distribution in the night is poor. Last nights data (when wearing my bipap) for instance was -
** Oxygen level >94% - 73% of the night
** Oxygen level 90-94% - 21% of the night
** Oxygen level <90% - 7% of the night

* this folder has my pulse oximeter graphs

dropbox.com /scl/fo/5846who689fwt7bhvnlpj/h?rlkey=2exnlnx3l9h19lue95dycxp2w&dl=0

* I used Oscar to download my Bipap data and it shows barely any correlated events. My AHI is 4.12 for the above night. The same link also has my stats from Oscar for last night

* Clearly the Bipap is not helping my low oxygen levels nor detecting them

* Here are my questions
** My oxygen dips have been occurring throughout the night as shown by the pulse oximeter but the AHI shows very sparse events, and infact most of them are clustered towards the end of the graph above as you can see. Why would that be? Why would my body go low on oxygen for so many times through the night while the Bipap machine seems to think I have barely had any episodes
** The higher clear airway index seems to suggest Central Sleep Apnea more than OSA? Is that accurate
** Will a mandibular adjustment device help with the above
** Will supplemental oxygen help?
** Are there any bipap devices that connect to a pulse oximeter and automatically adjust pressure based on oxygen levels going down as opposed to breathing patterns
** Have any of you encountered the above pattern?
** Are there any recommended devices, strategies, treatments?

Thanks

[gainerfull]

How clear is your nose on the average night? Have you tried running the same experiment after spraying afrin in your sinuses? How clear is your nose when you wake up?

[TechieHippie]

How long have you been using the v auto? It would be very helpful if you would post a screenshot (f12) of an Oscar graph with your oxygen data. It's hard to go off-site to look at files of data and an Oscar graph can show it very quickly.

Here are my off the cuff thoughts. It may take a while for the machine to help your oxygen level stabilize. Lots of things can affect oxygen levels including breathing patterns, and if you are just getting used to a new machine, it might take a little while for your body to adjust and relax.

Also, I think AHI 4 could be better treated if you fine tune your settings. I never realized there was so much space, so to speak, under 5 AHI.

Overall though, for someone who needs a BiPAP and I assume recently started, those oxygen numbers aren't awful. They aren't ideal, but I think they are decent enough that you have time to take things one step at a time. What is your average saturation?

Post an Oscar report along with the same night of pulsox data. In the meantime, see if you can relax your breathing into your lower lungs so that the belly expands rather than the chest. Wear the monitor some during the day and see if you have high daytime oxygen or drops with exertion. That will help us see if it's directly sleep apnea related or if your oxygen levels are fragile due to poor stabilization all the time.

Also, if you haven't, check other factors for sleep. Sleep position, pillow arrangement, potentially using mouth tape, all can be helpful. For example, if you have leaks, the machine won't always detect events, and mouth. Breathing can be hard on oxygen levels. That's why we need graphs. Hang in there, it takes time.

[bhavintu79]

Reposting - this time using the attachment feature for images. Cant delete the previous post. Apologies

Hello folks. Thank you for your quick response. Here are my responses

Techiehippie

• I have attached the full oscar graph and the pulseox graphs
  
• I have been using the v-auto for a month
  
• What fine tuning settings do you recommend?
  
• I have worn the monitor during the day and my oxygen saturation during the day is normal all above 95% so the device works and the breathing is normal during the day
  
• Will attempt the belly breathing
  
• I have attempted sleep position changes
  

gainerfull

• I actually use a nasal neti pot every night before sleep to clear my nose and sinuses. havent tried sprays. but nose has been pretty clear
  
• I do have a nasal perforation as a result of a botched up Deviated Nasal Septum surgery, but that does not impact my oxygen sat during the day
  

DrGizmo

• Will keep you posted if I find something out
  

[Gep232]

Have you got the "all in one" ring or the one that goes around your wrist with a smaller silicone ring for your finger?  I have the latter and found that it could be quite sensitive to position, often giving results like yours when everything else seemed fine.  I have found that wearing the silicone ring on my thumb and rotating it so so the cable enters at the side of the thumb not the top gives far more repeatable results......no guarantees but worth a try possibly.

[TechieHippie]

You are right, that oxygen doesn't look good. Those frequent drops into the low 80s are very problematic in my experience. I'm surprised your average is 95 instead of lower. 27 minutes of O2 under 90, often a lot under, is concerning.

It doesn't look like a sensor issue to me at all. Sensor issues have deep sharp spikes with normal readings around them. I would believe these reports unless you find otherwise.

You have a lot of central apnea still but I don't have the experience with those to know what setting changes might help. @Sleeprider or others may have thoughts. Your graph showed ps 5 over 5-25. Maybe try 5 over 7-25 and trigger high or very high of no one else chimes in. My instinct is to gradually raise EPAP to make sure your are getting enough pressure and see how the centrals react. If they increase with EPAP increase, reduce EPAP and increase PS to see what happens then. You might want to tune TiMax and min also. I have seen some text threads...If you have the brainpower search the forum for a combo of Sleeprider, TiMax, and centrals (then display by posts instead of threads) and look for situations similar to yours to get a feel for what those do.

I notice that your large leaks occur right after spikes in the flow rate and seen to line up with oxygen drops. That makes me wonder if they are troubling you and you lift the mask to get more air. That would imply more EPAP if I understand it correctly.

I'm curious about the centrals clustered at the end. Can centrals be positional too? I wonder if your body by that part of the night has just given up on breathing.

Almost 30 minutes a night below 90 might qualify you for supplemental oxygen at night. That would be something to consider especially for the short term. Avoid the mandibular advancement if at all possible, all I hear are horror stories of it messing things up.

Another novel idea might be the iNap device in combination with the BiPAP. I haven't tried it but am considering it after a recommendation. It draws the tongue and soft tissues forward expanding the airway.

Do you take magnesium, potassium, etc? Optimizing mineral balance can help sleep a lot. But this really feels structural to me, probably a pattern from your nasal problems and history.

[Jay51]

Dr. Gizmo, have you tried a soft cervical collar?  Before treatment, I had spo2 drops into the 80's and even high 70's from major, positional obstructive apnea (from chin tucking).  After the collar, everything stays usually above 90.  Just a thought.

[TechieHippie]

I just found the ResMed titration protocol, although it's only for S rather than Vauto. Still, it's interesting. Search for ResMed sleep Lab titration protocol and you'll find a PDF. On page 26 one of the things it says is for SPO2 less than 90% with all respiratory events eliminated, increase ipap and fall asleep lab protocols for adding supplemental O2. So even though your machine is not raising iPap much, this indicates that it could help to do so.

[TechieHippie]

Velpeau, caldera, are popular. I had to return one, then got a cheap one. What's most important is the sizing. Measure and go a little large because you wear them more loosely than if you were wearing them otherwise.

However, if you're rolling onto your back, there are various solutions to that from putting pillows behind you too sewing tennis balls into night clothes. I was just helping a friend and she picked out a squeaky dog toy.

However, given that most of your apnea is central, if I recall correctly, I'm not sure how much positional will help, it will be an interesting experiment.

Lisa

[croc297]

Following this thread with interest -- not able to answer your questions myself unfortunately, so hoping to learn from others as some of your comments resonate.

I'm using a resmed aircurve10 BiPap 16/12 pressure, auto humidity. Seems I still average over ~22 events (as defined by ResMed software) per night.  Also using a Wellue/Viatom Wrist/finger Pulse Oximeter -- that shows shows O2 dips at times to 70 or just above every night -- generally 5% or more of the recorded time O2 is below 90 -- that's 20 to 30 minutes per night depending.