SleepyCPAP’s Treatment Thread - Palatal Prolapse AlaxoStent

[Sleeprider]

We have known for a long time that Resmed does not chart flow limitation in any fixed pressure mode. The work-around is to use the auto mode with minimum and maximum pressure set equal.

[SleepyCPAP]

I do get FL reported in CPAP mode on my ResMed, just not in S-mode. The only reason I mentioned FL is because it can confuse the classification of the Hypopneas. In fact, what I’ve read suggests my VAuto won’t record Hypopneas unless FL is present.


The big question is the central or mixed Hypopneas emerging.  

There is not a lot about such Hypopneas.  I did find this research proposal for future scoring, and have highlighted in bold:

[Quote]
“Complex Sleep Apnea” by E.J. Heckman, R.J. Thomas, in Reference Module in Neuroscience and Biobehavioral Psychology, 2017
“Can Central Hypopneas Be Accurately Scored?”
An approach to identify/score central hypopneas is presented, which is based on the morphology and timing of consecutive respiratory events, oximetry patterns, and sleep stage effects, and mapping of coupled cardiopulmonary oscillations.
Suggested guidelines for central hypopnea detection are as follows:
1. Hypopneas that demonstrate concordant reductions in flow and effort, resulting in a waxing–waning appearance. Flow limitation is frequently present and is not used to exclude events.
2. All hypopneas that make up a periodic breathing sequence should be tagged as central hypopneas; events in such a sequence but lasting <10 min but at least 3 min or six consecutive cycles may also be considered.
3. Central hypopneas should not be scored in REM sleep.
4. The timing of respiratory events is near-identical, within 3 s of the mean durations in the given individual.
5. When oxygen desaturations occur, the drops are virtually identical and create a “band” of desaturation. In contrast, oxygen desaturation during REM sleep has an “irregular valley” pattern. Hypopneas that are part of a “band” should be scored as central hypopneas.
6. Opiate-associated/induced hypopneas have breath-to-breath amplitude and expiratory duration fluctuations. Events with these characteristics and otherwise meeting hypopnea criteria may be scored as central hypopneas.
7. Oxygen desaturation should not be a requirement to score central hypopneas.
Guidelines such as these could reasonably be “put to the test”—assessed in the sleep laboratory and prospective research studies to test inter-scorer reliability, clinical utility, and impact on management.
[end Quote]

[SarcasticDave94]

I'm just noting something, yesterday you mention you're doing well while today you're not. Why would I point this out? Building trends; which are more or less not available with 2 days comprised of 1 good and 1 bad sleep session. Point 2, the Hypopnea regardless of whether they're Central or Obstructive, there were only 4 this night. This is not a criticism, but trying to help so you don't travel into a rabbit hole of no events nights are required.

As for what type these Hypopnea are, I'm not sure which these are, but Central Hypopnea can exist.

[Sleeprider]

I think you are experimenting with low pressures to decide if you need PAP with the AlaxoStent or not. I think you should use the mode and pressure that results in your feeling best. If you want to sleep entirely without PAP therapy and observe the results using a recording oximeter, you should just go ahead with that, however I think these experiments with deminimus pressure below the threshold of comfort and good sleep is not very productive. You're welcome to pursue any settings you wish, however this has nothing to do with therapy optimization which is closer to my wheelhouse.

[SleepyCPAP]

Sleeprider and SarcasticDave94, I do think I’m doing well.  AHI 0.64 is fantastic.
I know it might seem I’m complaining, but I’m not.  I’m just trying to figure out what’s been going on as I decrease pressures. These Hypopneas are something to learn about.

Yes, at this point I am considering ceasing PAP therapy and just going with the AlaxoStent alone.  If this 4cm trial can be extrapolated to zero pressure, an occasional night with four Hypopneas and no desaturations below 91% isn’t going to be a problem.  Many nights in a row like that would not likely be a health problem.  That’s “treated”.

I’m holding at 4cm for a few more days to see how my body settles out.  I was six nights at 5cm, for example, and 5-7 days each at other previous pressures.

What has held me back from dropping the mask entirely?  After being used to looking at OSCAR I will miss that when I go off the machine - I never would have caught the expiratory Palatal Prolapse without seeing the tell-tale breath waves.  I’d want some way of spot monitoring, beyond SpO2 (I’d keep wearing my O2Ring).  So far the Contec RS01 does not load in OSCAR, and I haven’t bought one since I use a Mac and their software is PC-only.  

I also might not go off PAP.  But this (4cm) would not likely be the pressure I’d choose if I was going to stay on combined AlaxoStent and PAP therapy.  One of the higher settings with total zeros in all columns, rounded breath waves, and perfect “10” score on the O2Ring would be more logical, if overkill.

[Gideon]

If the low pressure looks good, request a diagnostic sleep study (without CPAP) to see if the AlaxoStent only works. It is the only way to be sure.
If it works, use the CPAP at low pressures once a month/week to spot-check things. Keep a baseline low-pressure chart available for comparison.

[SleepyCPAP]

OK, my doctor authorized the home sleep study (Type II). I have a question about washout period.

In the meantime I've set the VAuto's min-EPAP to 4 (since it is the lowest VAuto will go, and I know from the above declining pressures experiments that days of straight CPAP 4cm kept my AHI below 1, with hypopneas only). Also because my best balance (breath shapes, no 95th% FL, zero AHI, rare or no CA's, perfect "10" on O2Ring software) seemed to happen at PS 3 or PS 4 at min-EPAP 4, I've set PS to 3.4. The max IPAP is 10cm (never got up to that with AlaxoStent use so this is a high ceiling).
PS 3.4 over 4 to 10 cm.

So, I'm getting fantastic combined therapy, but that means my body is used to combined, not used to the stent alone. I've heard doctors ask for a washout period.

What is the wisdom here - should I just use the stent by itself for a week leading up to the home sleep test with the stent? I'm not sure I want to do the washout in my bed though, maybe in my recliner, because I ended up with a mild headache after a whole night with just the stent.

My O2Ring statistics are ok during a few naps or the whole night with just the stent. (avg. 95% SpO2, minimum doesn't go below 90%).

[Gideon]

Since the purpose is to see if the stent will work on its own, I'd go a week without PAP prior to the test. Use your oximeter to validate no significant desats.
Your headache indicates that you may need the combined treatment for comfort if nothing else.

[SleepyCPAP]

Gideon’s advice matches my Sleep Doctor’s Office.  I had to contact them to ask about a washout period, because they hadn’t given the instruction when the home sleep study was authorized. They too said one week with just the stent, as washout, before the test.  I saw a study (link below*) where it looked like fairly accurate results could be obtained by the 4th night of washout, but I’ll try for a week (may be six days considering what is on my work/home schedule).  That puts off the study for a couple more weeks because some work demands won’t be so bad (I hope) that particular week.  I’m expecting I’ll be functioning less than perfect during this washout adjustment.
*“Effects of continuous positive airway pressure therapy withdrawal in patients with obstructive sleep apnea: a randomized controlled trial” (Am J Respir Crit Care Med. 2011 Nov 15;184(10):1192-9).
https://pubmed.ncbi.nlm.nih.gov/21836134/

I’m also looking deeper into my RingO2 data so that I have a more solid feel for how I do with just the stent, compared to my current combined stent & VAuto therapy.  I thought the O2_Insight_Pro software would be good enough, because it includes a graph, but it looks like (from last night’s example) it doesn’t chart >= 95%, it lumps 95% with the lower bar.  Given my sex, age, and elevation the 95% SpO2 figure should be in the good column. So I may chart the CSV files on those nights myself, and use last night as a comparison.  
   

I’ve been silent here because my treatment has been great. Although I’m usually averaging 96% SpO2, last night was a point off but I didn’t have a great bedtime routine and that can sometimes make a difference in waxing/waning during the night. Bleep Mask with PS 3.4cm over 4cm in VAuto mode does really well for me, and will likely be what I return to after the home sleep study and for the foreseeable future.  I think I’d do fine at EPAP 3cm IPAP 6.4 in “S-mode” (since I got all nights 0.0AHI at 3cm/6cm during previous weeks’ experiments) but of course that does not report FL, and can’t auto-adjust for a bad night. Last night the VAuto went up to 8cm IPAP for an instant, to deal with one of the few FL. Most nights it hovers at set pressure.  Overall FL was 0.05 for last night (OSCAR 99.5% column, and zero at 95% column).

Thanks all for the support in getting me to this nice outcome!

- SleepyCPAP

[Sleeprider]

I still think this has been a fascinating conversation because you had a severe breathing disorder, but CPAP was not the answer, and may not even be part of the answer. It's great you found something that really works, even though U.S. medicine and insurance has not caught up to recognize it yet.