Please advise on teen's issues (OSCAR data)

[SnoNoMo]

Hi all,

My teen (17) had severe life effects from untreated mild (for adults, qualifies as moderate for pediatric -- AHI of 7) sleep apnea.  CPAP, since October, has been a huge help in terms of fixing the effects (alertness, cognition, energy), but lately (last few months) she has been experiencing debilitating aerophagia, which seems to have set off rumination syndrome.  The aerophagia occurred even one night when she only used the cpap for 90 minutes early in the night when she typically has no apnea events.

She tried the BongoRx, which eliminated the aerophagia and rumination, but it did not work for the sleep apnea (going by feel -- she was tired, headachey, and generally felt as she did during the long untreated stretch).

She tried a full face mask, which didn't help so went back to the nasal one.
We have a nasal pillow mask on its way to try next.

She has a wedge pillow, but doesn't really use it as intended.

She rolls around a ton.

I have posted OSCAR data from a recent night of restful sleep. I can post more from this night if that is useful.

The questions I would love for you experts to weigh in on are the following.

1. Can you see any reason for the aerophagia? Or think of something to try?

2. Can you say anything about positional issues?  Do you see any signs of that?  She didn't like using a collar the few times she used it. I can put more effort into that and she'd be more willing if you all see evidence of that. (I am unsure of how you id it with OSCAR data).

3. Can you tell where in her 'air tube' the obstructions occur, e.g., soft palate?

[gainerfull]

Please consult your kid's sleep doctor first and foremost but two things you may consider is either tightening the range for APAP mode or switching to constant pressure (CPAP). The aerophagia can likely be attributed to the pressure spike and the increased pressure blowing her mouth open at night. Once she's mouth breathing with only a nasal mask on the machine cannot compensate so it will stay high and is likely forcing air into her stomach as a result.

Did she do a sleep study? What was the best pressure for her during the titration (sleep study)?

Looking at the pressure it looks like it spikes after a cluster of obstructive events so it's likely that the minimum of 5cmH20 is not sufficient to keep her airway open. Another thing to consider is it looks like she's mouth breathing based upon the leak rate and nature of the leak data.

If this were my daughter I'd try the following:

1. Solve the mouth leak with tape, chin strap, or try a double sided boil & bite mouth guard (whatever is most comfortable)
2. Set minimum pressure to 8, max to 12 and keep EPR at 1 for auto mode for 2 nights to see if a higher minimum pressure and no mouth leaks result in lower pressure needs
3. If #2 doesn't produce great results and reduce aerophagia then maybe consider switching to CPAP mode and starting at 8cmH20 and reviewing data each night

The key is to find the absolute minimum therapeutic pressure for her that doesn't cause aerophagia.

[SnoNoMo]

Thank you for your response.

She did have a sleep study, at a children's hospital, where her untreated AHI was 7-8. She never was put on a cpap during it, so no titration.

For pediatric patients, after diagnosis, they first make them get checked out by an ENT to see if tonsils or  adenoids are causing blockage (hers are v small) and only then do they move on to prescribing a CPAP.

The Dr. used default values of 5-15 for the range.

Her AHI numbers are often <1, even with min pressure of 4.

We will try moving up the minimum pressure.

[gainerfull]

How'd it go? Any luck?

[SnoNoMo]

She set her min pressure to 8. She had an AHI of 1, which is in her range.

The aerophagia was maybe somewhat better. I think we'll need to see how it is over several days since there is some variation.

I cannot look at data for about a week or so. She goes to a boarding school. I took her SD card from her cpap machine when I saw her last weekend. I mailed her a couple SD cards so she can record the data and mail it back to me.

I am heartened to try the narrower range, and have a go at constant pressure if the narrower range isn't enough to stop the aerophagia. I appreciate the suggestion.

[SnoNoMo]

Hi. Okay the 8-12 with EPR is still resulting in aerophagia. 

So tonight she'll do 8 (min & max) without EPR.  Her AHI is 1ish.

[SnoNoMo]

After talking to her it came out that she didn't tape her mouth. So we'll not change the setting but tape her mouth.