SleepyCPAP’s Treatment Thread - Palatal Prolapse AlaxoStent

[SleepyCPAP]

I did step down the Pressure Support last night. I am now using the combined AlaxoStent and VAuto at PS3 over 4-9cm.

In my recent experience the first night after a pressure reduction is usually not my best. If that proves to be true for this new setting too, then this pressure setting will be really good, much like the last.

No need for OSCAR shots. AHI 0.0. SpO2 Median 96%, above 95% for 90% of the night, lowest is one brief dip to 91%. 99.5% column shows: Leaks 0.00, Snore 0.00, Flow Limitation 0.07. Median pressure 7.08 cm, 95% pressure 7.9 cm and 99.5% pressure 8.1 cm. No hint of Palatal Prolapse when zoomed-in to look at breath waves.

We’re now in the range where my plain ResMed Airsense 10 Autoset or “For Her” model could be used in combination with the AlaxoStent, since 4-9cm with EPR 3 would be equivalent.

[BKeeper]

Nice! Now at levels suitable for an apap! Including a travel machine, I assume. I really look forward to your continue doing titrations, Sleepy!

[SleepyCPAP]

First night in "S" mode (not VAuto) so that I can get a lower setting (manual says S mode can go down to 2 cm for EPAP, but VAuto can only go down to 4cm).  Setting was EPAP 3 and IPAP 6 cm.  I was breathing hard when I first went to bed, because this pressure is starting to feel a bit too low.  I may need the next few days to get more adjusted to this feeling.

I am continuing to find success with the 6" AlaxoStent combined with PAP therapy.  It doesn't seem to matter how low my pressure is set, I keep getting 0.0 AHI.  My IPAP is now at (or below) where my min-EPAP was set a month ago (min-EPAP used to be 6 or 6.4cm).  My IPAP used to go to 14cm on bad nights.  This continues to affirm that the AlaxoStent is still doing the major part of the airway opening - and I suspect it is doing _all_ the work and the machine is just there to record the breaths.  Remember my original prescription was 11cm CPAP way back when I was first diagnosed with severe Obstructive Sleep Apnea.

No leaks (taping mouth along with poligrip strips on lips). Bleep Mask. Wedge Pillow and Cervical Collar.

I'm not sure OSCAR reports correctly in S mode.  Flow Limitations are always shown as 0.01 across the whole graph.  Here is the whole-night view:
   

Here is a closeup where I see flattening of the curves, but OSCAR is not showing spikes on the FL chart (I also put a post in the Software forum):
   

I'm seeing evidence that CO2 regulation may be variable at times.  Waxing and Waning has shown up on different nights, and last night was no exception.  Unlike my time on Philips Respironics machines, I don't see this Periodic Breathing highlighted by ResMed so I just grabbed a screenshot of one time.  It isn't a pattern that is constant, indeed most of the night doesn't have this.  I've seen this come and go in all 11 years of PAP therapy. Overall my O2Ring was showing great stats for the night, and brief dips never went below SpO2 93%.
   

Sadly I did not sleep well.  Maybe my late dinner was bothering me.  Maybe work stress.  After I got up to the bathroom I never went back to sleep (those stats are included, but as there is nothing different about them it doesn't throw the rest of the night stats off).

- SleepyCPAP

[Sleeprider]

The stimulation of the stent may actually be treating most of your obstructive apnea as well as PP. You appear to be someone that can just use CPAP/BPAP for comfort rather than necessity.

[cathyf]

I would be interested to see how vauto with PS=3 compares with autoset EPR=3 for you -- my experience is that they are not the same. I think it's that EPR=3 is equivalent to a "VeryHigh" trigger sensitivity on vauto -- at least I see on the autoset that the mask pressure lurches all over the place in response to every trivial flow rate wiggle, where it only does that with the vauto if I set the trigger sensitivity all the way up.

[SleepyCPAP]

I understand the EPR settings are baked in, rather than with flexible trigger settings that are available in the Aircurve 10.  I remember reading in your thread, cathyf, and deciding to set my VAuto to “high”.  It works for me.

I could have jumped over to the AutoSet and compare, but my goal at the moment is to see how low I can go before AHI rises significantly above 0.0.  So I switched to “S” which can go to three (where it is now) as min-EPAP, or even (according to manual) two as min-EPAP (next step down after four more nights?).  Maybe another time I can pull out the AutoSet.

Snapshot of the declining pressures for the past week (since I’ve been going just five nights at a pressure, this shows three pressure settings):
     

- SleepyCPAP

[SleepyCPAP]

This night I switched from the VAuto "S" mode to AutoSet in CPAP mode to get FL and RERA readings. The CPAP did not have any RERA tonight, but had occasionally scored them in the past, so it is capable.  Still combining AlaxoStent and PAP therapy.

Even though EPR is set to 3, it was limited by the 4cm floor baked into the machine, so was only 2cm.  This is as close as I can get to the previous "S" mode of 3cm EPAP and 6cm IPAP.  I know my FL would have been better if the full 3cm EPR had been usable, I am curious what people think of the amount of FL reported here.

   

I was not able to sleep when I went back to bed after getting up for the bathroom at 4:50am.  The bad FL in the beginning of that short session is fixed around 5:00am when I changed my position on the wedge pillow. So even when I'm awake my breaths are not perfect. Turning off this non-sleep session (and its corresponding SpO2 data) does not significantly change the left hand columns (the FL would have been max 0.20 without the non-sleep session for example, instead of 0.21).  Yes, I did take off the mask at 5:35 (high movement) but left the O2Ring on while I laid there awake (rolled on my right side at that point, which brought down SpO2 by a smidge).

The Bleep mask seals very easily at this low pressure.  It helps that when I tape my mouth with the 2" KT tape I overlap the lower edge of the Bleep Dreamport seal where the stent comes out of my nostril.  I don't bother showing the empty leak chart in OSCAR.

I had one User Flagged event- not enough to get a full scoring designation by the machine.  It didn't cause a desaturation on SpO2. You can see the closeup of the less than perfect breath waves:

   

My O2Ring had the right numbers in the left column, the minimum, maximum and median are very similar to most nights.  But a closer look at the Insight Pro software graph shows I spent a lower percentage of time above 95% compared to other nights (it was only ~40% in the 95-100 range, compare that to the ~90% shown in post #50).  The lack of 3cm pressure support shows up at this setting, so I'm getting the sense the stent's magic is great enough for achieving 0.0 AHI but maybe at this 6cm setting or lower (without full 3cm EPR) super-perfection is not going to be possible.

   

- SleepyCPAP

[SleepyCPAP]

I'm now down to 5cm. 
I tried two settings - "S" mode EPAP 2 and IPAP 5cm during an afternoon nap, and then at night did CPAP mode 5cm with EPR (which was limited to EPR 1 due to the 4cm lower limit). 

0.0 AHI for the nap, and 0.14 AHI overall, due to one hypopnea in the night during CPAP mode.

The S mode gave me higher tidal volume (median=600, 95%=900, 99.5%=1440) compared to the CPAP. CPAP stats were closer to my usual Tidal Volume for previous nights (median=480, 95%=860, 99.5%=1080).  Basic SpO2 stats were identical: Average 96%, Low=93%, High=97%.
No SpO2 drops over 3%.  Looking more closely at the Insight Pro software for the O2Ring, it appears 75% of the time I was above 95% SpO2 when in S mode, and 80% of the time I was above 95% in CPAP mode.

No Flow Limitation reported in S mode, but with the 3cm PS it didn't seem I was experiencing any FL when I looked at the breath waves. 
In comparison, FL in CPAP mode was 99.5%=0.18, 95%=0.08, and Median=0.00.  Breathing looks a bit more ragged.

I'll repeat CPAP setting at 5cm for most of this week and report back if anything drastically changes.

I needed more sleep, but a late bedtime and early bathroom trip seemed to be the culprits, not the AlaxoStent and PAP therapy.

Question:  at what FL numbers do I be concerned?  
My short "laying in bed trying to get back to sleep" time after the bathroom break had FL 99.5%=0.11, 95%=0.09, and Median=0.00. I've seen FL during other wake times too. That leads me to believe the amount I had while asleep isn't far from my body's "normal", but the question is still valid.

- SleepyCPAP

[SleepyCPAP]

Long post. First two paragraphs are short summary, then I get into the details.

I switched to 4cm pressure tonight. Still using AlaxoStent and combined PAP therapy (VAuto in S-mode this night, EPAP 3 & IPAP 4). Wedge pillow and Cervical collar. Taping mouth. Switched masks in the middle of the night due to panic at this pressure.

Still getting great results.  Not a zero night, due to two hypopneas in the early morning hours. AHI a very nice 0.24 overall. I'd seen a couple nights with one or two hypopneas during the previous six days at 5cm, along with zero AHIs (or just a CA or two), so the stent/PAP combo is doing _very_ good therapy.  SpO2 averaged 96% for night, with a mere 16 seconds below 90%.

Now the long version ————————>

Nuances are visible deeper into the data. Sadly I can't get FL reported in S-mode, but I expect the FL to be similar to a few days ago at 5cm in VAuto mode which was FL 0.13-0.17 range (99.5% column). Same PS=1 for both, except last night was 1cm lower on both EPAP and IPAP since S-mode allows that.  See zoomed screenshots for an idea of the breath waves.

I started the night with my Bleep Mask. After only a few hours I got up to use the bathroom and couldn't stand the Bleep Mask when I went back to bed - felt I wasn't able to get enough breath at 4cm. Panic! I got up and read a good book for a little to calm down, and switched to TAP PAP mask (just a hunch that I'd be OK with the way that breathes).

Heart rate in the first part of night (Bleep Mask) averaged 76 & 78 BPM. Heart rate during TAP PAP part of night averaged 71 BPM. Compare to 64-69 BPM averages prior to tonight. I suspect my middle of the night blood pressure was not the usual resting rate, I hadn't thought to check it when I was up. As a heart attack survivor every little stressor counts.  Avoid panic!

As I summarized above, the average SpO2 was 96% for both masks (and the whole night), but they were not the same in subtler ways.
Despite dips to 89% SpO2 during the TAP PAP session, and 31 Drops over 3% (of which 18 were over 4%) overall 65% of the time Sp02 was above 95% (and only 16 seconds total below 90% SpO2). In comparison, I didn't drop below 91% with the Bleep Mask, had only 3 times of drops over 3% (one 4% drop), but oddly only 55% of time above 95% SpO2 according to 02_Insight_Pro. No perfect “10” scores for SpO2, compared to higher pressures where that happened.

Snores were scored early in the night with the Bleep mask (but I can't see the actual squggles in the waveforms when I zoom in), and my lips leak once I put on the TAP PAP (tried taping and PoliGrip strip, but there is no way to fully seal with that plastic piece sticking through the lips).

The waxing/waning patterns through the first and last sessions lead me to believe CO2 management is difficult at this low pressure. I don't know if venting is sub-optimal when the machine is down around 4 or 5 cm pressure.

The main lesson I take from last night is to not stress and panic. I suspect that may mean staying with the TAP PAP, or trying my Swift FX or P10 nasal pillow masks. I've loved the Bleep mask very much at any other pressure but not at this one.

I’ll include three snapshots from OSCAR.

Whole night:
   

Waxing and waning (this example from Bleep mask session):
   

Wax and Wane with Hypopnea (TAP PAP session):
   

- SleepyCPAP

[SleepyCPAP]

Please comment on mixed or central Hypopneas, what you know about this, and how to eliminate.  

I am more convinced that the low pressure setting is aggravating my CO2 regulation.  It seems as if the mask vents don’t work well at 4cm or less.  But I’m not familiar with wisdom around this, and my quick glance of searching “central hypopnea” just gets examples of those words in the same post, not what I’m looking for.

This is just one example from last night, where the hypopnea was scored in the Wax/Wane low point. I’ve seen this on other nights and at 5cm too.
   

I know the official scoring says this is an obstructive hypopnea, or at least “mixed”. Even if I had an effort-measuring belt that said it wasn’t obstructive, the presence of flow limitation breaths disqualifies it, officially, from being Central. 
https://www.aastweb.org/blog/scoring-obs...e-criteria
 But I don’t think I would have had these four Hypopneas last night if I hadn’t had so much periodic breathing. The flow/effort strain does not look like the FL is the real issue. 

My original sleep study showed central apneas, mixed apneas and mostly obstructive Hypopneas. That was 2010, so scoring criteria might have been different and “mixed Hypopneas” might not have existed as an option.  Through my years of CPAP my recalled PRS1 machine would sometimes find periodic breathing and score it with green.

I was going to switch to straight 4cm pressure tonight anyway.  While that won’t help the FL, at least the FL will be measured (I’ll either use VAuto or CPAP mode, and they do score that - last night’s S-mode won’t). Maybe without the PS=1, no variation, it will help with CO2 regulation a little.

Tidal Volume was low last night too.  Just 400.