SleepyCPAP’s Treatment Thread - Palatal Prolapse AlaxoStent

[Rubicon]

In re: arousals, all respiratory events usually have arousals. However:

You don't need an arousal to score an apnea;
you need an arousal OR a desaturation to score a hypopnea; and
you totally need a arousal to score a RERA (one could argue that the the event is the arousal, not the respiratory disturbance).

[Gideon]

Rubicon I suspect that the algorithm doesn't count arousal associated with RERAs as Respiratory arousals because they are already accounted for in the RERA.
Do you have information stating otherwise?

[SleepyCPAP]

Rubicon,
Here is his quick follow up response to the great question about RERAs not showing in the numbers:

“RERAs are always with an arousal. Required for it to be tagged, so arousal always assumed and not included in total resp arousal index. (system won't allow it to be tagged that way)”

Seems then to be a Respironics software issue. Alice PDx was the equipment, I don’t know the software associated or its ins and outs. (Gideon, this fits with what you said above) I don’t need to know, I just am glad to be able to point out the discrepancy to my doctor.

He confirmed what you said about the count of OA and H not needing respiratory arousals. I had two without. My mistake for not understanding the scoring rules. Thanks to both you and him for educating me.

He did not know why the hypnogram had pulse/heart rate at the 30 BPM line, unless it was charting from a different data source. To me those heart rate lines look more like a flag of heart rate magnitude jump, not related to the markings on the Y-axis. The O2Ring gives a once in four second number in its reports, so I’m guessing my peaks from the O2Ring software are missing some tips, but the first two big lines on the sleep study correspond to significant magnitude peaks on the O2Ring app.

So, my take-away is to ignore the Respiratory Arousals chart numbers on the Respironics sleep report, and instead look at the RDI and RERA count.

My guess is the reason why I feel better when combining treatments (compared to the washout week with just the AlaxoStent) is because all (*most of) those RERAs are eliminated with the dual treatment. I’m not being disturbed those extra 11.7 times an hour. I can also point to this when I explain to my sleep doctor why AHI<5 doesn’t make me feel fully treated. RDI on a real sleep report begins to look like something my doctor trusts. At the moment I don’t need to push, because my doctor did approve the VAuto back in November and it (with the addition of the stent in December) have made it so I don’t need any more troubleshooting. (Go AlaxoStent - one less patient taking precious appointment time in a busy Lung & Sleep practice!)

The AlaxoStent would be great by itself for someone who can’t adapt to PAP therapy, or throws it off in the night (or like me will cuddle with my spouse and fall asleep before masking up, with just the stent in until I wake later and realize). This study shows me the Severe OSA is reduced to mild RDI, and oxygen is in a much better range (even as I still say that reported number is mistakenly low). The AlaxoStent is doing most of the work, and my one personal example backs up the study they tout and justifies the FDA approval. But I just happen to adjust well to PAP (over 11 years now) so my body and brain knows I can get “perfect” treatment with both together.

My old PRS1 used to flag RERAs generously which would show up in OSCAR, I don’t think the VAuto flags RERAs, it just shows me responses to FL (slight pressure bumps) associated with the rare FL that slips through. The VAuto shows me enough info on the screen that I can tell I had minor/rare amounts of FL before loading the card into OSCAR, because I can see the 0.0 AHI but then scroll down and see the 95%tile pressure was up 0.2cm from the base setting (4.2 EPAP listed there this morning, compared to the base setting of 4.0 EPAP).

Thanks again for noticing the discrepancies. This is really helping me look deeper than the front page.

[Geer1]

Arousals should be scored in the arousal section regardless of whether they are reported as a RERA elsewhere in the report. Not doing so makes that arousal section of the report misleading. It will be interesting to hear their reasoning for not doing so.

The majority of those RERAs occurred during rem sleep with an RDI of 22 during rem. The stent has proven effective in maintaining nasopharynx patency so I would imagine those RERAs are occurring due to restriction lower in your airway. Concurrent CPAP use may treat those RERAs and maintain better rem sleep. The hard part is titrating since you can't score RERAs at home.

Out of curiosity now that you have proven nasopharynx restriction and palatal prolapse is a significant portion of your issue are you considering UPPP?

Edit: And response was posted before my post. Sounds like they would need to score both a RERA and a respiratory arousal at the same time for the software to score it properly (if that is possible). Seems ridiculous PR's software wouldn't be set up to score RERAs properly.

Your comments mirrored my own about concurrent CPAP use which makes sense from an anatomy point of view.

[SleepyCPAP]

Geer1,

No, I want to avoid surgery. The stent is the perfect non-surgical alternative treatment for the soft palate collapse. So far as I can tell (three months in), there are no side effects, and efficacy is consistent.

Before the washout I was at PS 3.4 over 4cm, and after washout I bumped that up slightly to PS 3.6 (still at 4cm).

Titration came from watching OSCAR as I was reducing pressure after adding the stent, every 5-7 days. My best numbers were in the PS 3 or PS 4 range, with a 4cm EPAP. Then, going lower, even CPAP at 3cm still eliminated OA’s, but FL’s and H’s were present. Technically, according to ResMed’s titration guide, 3cm would be OK for EPAP. I suspect that if the VAuto let me set EPAP to 3cm, I’d do well with PS 4 over 3cm - but alas the machine I have doesn’t set that low except in “S” mode (which ResMed decided won’t report FL’s, unlike CPAP which does, and I want to see FL’s in OSCAR). My first titration 11 years ago (prior to onset of expiratory Palatal Prolapse) ended up with a CPAP setting of 11cm, and I don’t remember them saying it eliminated RERA’s (indeed the PRS1 data showed RERAs, even on low AHI nights). So being around 7cm IPAP is a big improvement, as is the reduction of FLs.

[Rubicon]

That RERA reporting is certainly confusing, but needn't be.

Normally when scoring events, you'd highlight the event and then a pulldown would appear and you would select the appropriate event (i.e., hypopnea, hypopnea with arousal, hypopnea with desaturation, hypopnea with arousal and desaturation) and off you'd go.  Or you'd score all the events and hit the "associations" button and if desats and/or arousals were close by they'd be picked up.

Seems like AASM would have a problem with that report, but I ain't them.

Only used Alice a couple times a long time ago in a trial.  Wasn't a big fan.

[SleepyCPAP]

I don’t post or sign on much anymore, because all is well.  

Reminder:  In the 30 days prior to my using the 6” AlaxoStent my machine scored 489 Obstructive Apneas, despite my 99.5% Flow limitation averaging 0.019.  That indicated to me that PAP pressure was correct for inspiration, but expiratory Palatal prolapse was closing down my throat.
I then started the AlaxoStent in December, 2021.  In the year since starting stent use (combined with VAuto) my total Obstructive Apneas have been 7, and my 99.5% Flow limitation is averaging 0.032 (median pressure 7.48).
So, use of the stent with my bilevel brought down my Obstructive Apneas from 489/month, to 7/year, all while decreasing my average pressure on my VAuto (with the side benefit of no more air leaking into my belly at high pressures).

OSCAR calculates my average AHI over this past year is 0.042.  That included early days of going down to as low as 3cm CPAP, to see how well the stent was doing on its own, with Hypopneas appearing at that low pressure.  Since dialing in my current pressure (over ten months ago to EPAP 4 & PS 3.6cm), my AHI has averaged 0.022.  Occasional random, short, CA’s or H’s slip through on some nights, but I’ve had a whopping 293 nights of 0.00 AHI in the past year.  That means 80% of my nights are AHI 0.0 in the past 365 nights (86.7% since current pressure setting 10 months ago) !!!

I have not noted any negative side effects from use of the stent.  No nasal or throat infections, for example.  

A previous post mentioned that I had a sleep study with the stent alone, and it brought my AHI down from severe to mild - so sometimes I take naps without masking up, knowing I’m doing ok.  I wear my O2Ring so I that’s how I know I’m doing OK.

[Sleeprider]

Very helpful information. Have you contacted AlaxoStent with any of this data or pointed them to this thread?

I have edited the Optimizing Therapy wiki section on Palatal Prolapse to reference this thread http://www.apneaboard.com/wiki/index.php...l_Prolapse

[DLEWIS]

Re: SleepyCPAP Treatment: Thanks for your information. I have palatal prolapse breathing patterns which was confirmed by a sleep expert. I've ordered the Alaxo 6" stent. I just starting using a Wellue O2 ring. I posted a new thread today: Alaxo 6" stent and understanding pulse results  

Would you be able to take a look at it and let me know if you have any insights.

Thanks for all the information you have shared!

[AndyB]

Hi SleepyCPAP,

I've been reading your extensive and detailed thread about palatal prolapse with great interest. Although I'm not facing the cardiac issues you faced, I've been on cpap therapy for 8 years and recently started to have significant palatal prolapse episodes.

I am very grateful for the education your thread has provided (and for several other helpful threads about PP) -- it has given me a whole new understanding of PP and the various ways it may be addressed. For now, as I dive into that process, I would appreciate a small bit of advice about setting up OSCAR to flag my PP events.

I understand I can set up custom user event flagging in OSCAR's "preferences > CPAP" settings, but I have no idea what criteria to use to identify PP events -- what do you suggest? It appears that the only criteria I can specify are the levels of flow restriction and event duration. What do you use, and why, if I may ask?

I would be very grateful for any thoughts on this you're willing to share with me (or anyone else out there who may know the answer to my question . . .Sleeprider? Gideon?).

Thank you,
AndyB

ps - for what it's worth, I'm a 78 year old male in otherwise good health with normal BMI; my apnea is the result of a small airway, according to my doc.