Need Help Advising a Friend

[Melman]

I am trying to help a friend who is not sufficiently computer literate to use the forum. He was diagnosed with severe sleep apnea (AHI 46.4) by a home study. I helped him get and set up an airsense 10 autoset with a pressure range of -20 and EPR of . His AHI fluctuated between 3 and 9 with most nights below 5. I observed clustering of OA and too many CA events so I got him to use a cervical collar, increased min pressure to 8.6 (meant to change it to 8) [/color]and reduced max pressure to 14. His numbers improved and he said he felt well.

I failed to follow up until recently when his wife told me he felt fatigued most of the time and he was experiencing frequent headaches. He told me he’d been taking his SD card to his specialist who said his data looked great. I just got his card and the data looks much worse than earlier. I’m worried he has complex apnea but there is no way he can afford an ASV. I’m hoping I’m wrong or that the settings of his current machine can be adjusted to improve his therapy.

Although he has a soft cervical collar he admitted he does not always use it. I think that shows in some of his charts. Although he often has a preponderance of CA they are often clustered. His wife tells me he is an extremely active sleeper.to the extent that she often has to move to the couch. It makes me wonder if many of the CAs are due to holding his breath when he moves. On some nights she gets him to use essential oils and he sleeps calmly. I have attached his sleep study and several daily charts and would appreciate suggestions on what to change. He has agreed to wear the collar consistently. I’m thinking reduction or elimination of EPR may help.

I’ve asked his wife to keep a log of when he uses the collar and how calmly he sleeps in hopes there will be some correlation with his daily charts. I have attached his sleep study and several daily charts. (See followup post for two more charts.) Any suggestions will be appreciated.

[Melman]

Additional charts.

[SarcasticDave94]

If CA is suspected to be working against your friend, a few things I would do with the goal to minimize pressure swings. Reduce or eliminate both ramp and EPR. The sleep study oxygen info is a red flag of possible supplemental oxygen as medical necessity; it states average of 89% and low was in the 70's%. An average of 89 likely means a considerable amount of time is less than that 89. This indicates potential of meeting medical requirements for oxy. FWIW when I had my bout of pneumonia last July, oxy was helpful in breathing.

[Sleeprider]

Very good interpretation of the study by Dave, and I agree the oximetry data is a continuing concern, and should be checked during sleep with the CPAP if you can get your hands on a recording oximeter for a night. The sleep study showed some very long duration and clustered OA which s consistent with the positional apnea you are using the collar to improve. No CA events were noted in the stvudy.

Obstructive events seem to be fairly well controlled with pressure of 8.6 to 12 and EPR 2, with rare appearance of flow limitation. CA events are very inconsistent which may argue in favor of the idea they are related to physical movement rather than being related to EPR or the PAP therapy. The best way to monitor this is to ask his wife to keep a log noting the nights he is more active and see if that correlates to the CA events. If movement seems unrelated to the clusters of CA, he might be treated with a pressure range of 8-10 with EPR off, and see if this results in the desired reduction of CA. I think maintaining positional therapy using hthe collar remains a high priority. You done good Melman!

[Melman]

Thanks Dave and Sleeprider. I didn't do that well. I should have picked up on the oximetry data. But then, his Dr. should have. As for no CAs in the sleep study, I thought home studies couldn't detect CAs. Am I mistaken? Anyway, I will follow up on your recommendations and report back when there is more meaningful data. I spoke with his wife again and she has started the log.

[SarcasticDave94]

I'm not absolutely certain, but I think some home studies may include the belt for chest monitor for movement/breathing data. I'm thinking that is the key to deciphering CA. There has to be an input sensor for chest movement to say there's breathing effort or not. No effort typically indicates CA.

[Melman]

You may be correct, Dave. I reread the report and a belt to record respiratory effort was included.

[Melman]

It's been a month and the data are not what I hoped for. His wife kept a log recording collar use and how calmly he slept. He used the collar every night. For half the nights that he slept very calmly his AHI was in the 3-5 range and for the other half it was 7.16-9.07. Most of his worst nights for CA, both absolute number and significantly greater than OA were nights he slept calmly. So it does not appear that his CA events are associated with tossing and turning. His statistics for the period were avg. AHI 6.23, OA 2.50, CA 3.48, H 0.23, and RERA 0.02.


He had an overnight pulse oximetry test with low SpO2 of 73% and 137 min below 88% over a 7hr period. Unfortunately it appears he did not use his APAP the night of the test. They can’t recall if he used it that night but since there is no data for just that night but data for all the preceding and following nights I strongly suspect he didn’t, especially since the results are almost identical to those from his original sleep study. Fortunately his Dr. has agreed to order another overnight oximetry test.


His Dr. wants him to go for a titration study which he says is required by insurance for supplemental oxygen. I’m hoping the results of oximetry with APAP use will rule out the need.

For now I think elimination of EPR and narrowing his pressure range as Sleeprider suggested earlier may help. The ramp needs to go also


I have posted 3 charts. The first two are from nights he slept very calmly, June 19 and 21.


The other is from a from night he tossed and turned a lot, June 26.


Any recommendations will be appreciated.

[SarcasticDave94]

FWIW the RT at Apria that handles my ASV told me to do a 5 minute walk test then take an oximetry check that was done by the nurses at my pulmonary docs. This was to signify medical staff controlled the testing. If it was less than 89%, oxygen script for a portable oxygen concentrator (POC) would be required. That's obviously in a waking status.

I think the 5 minute/less than 89% applies to sleeping as well for supplemental oxygen, whether on PAP or not. The PAP aspect needs factored in when calculating L/min values.

PS I've been on actual Medicare since 5/1/2020. Prior 4 or so years was Medicaid; they emulate Medicare requirements.