SleepyCPAP’s Treatment Thread - Palatal Prolapse AlaxoStent

[SleepyCPAP]

Short version: I am starting this thread at the suggestion of Sleeprider because Flow Limitation and imbalance of inhale/exhale was noted in what I submitted for an OSCAR question.  I have moved from PRS1 “Pro” (which didn’t flag Flow Limitations) to a ResMed Airsense 10 Autoset - due to recall.  It is new to me and CPAP>>APAP is still new to me.  I’m experimenting with mode and pressures, and EPR.  I see waveforms not present before this summer which suggest I’ve developed Palatal Prolapse. This might also explain why I didn’t like EPR2.  Also, I can be disturbed by pressure changes and leaks.  I’m using the Bleep mask since July 1, and 3M micropore tape on my lips.  I want satisfying sleep with the fewest disturbances, and assurance that I’m being treated even when I’m not looking.  
(More details below, or skip right to screen shots next post.)


Background for this therapy thread long version:

I am a middle aged man, currently with upper end of “normal” BMI.  Historically I started my treatment as “Obese” at titration in 2010, brought BMI down to “normal” by 2014 (and neck size), but nudged barely up into “overweight” during COVID, briefly, before returning to “normal” this summer.  I do not drink alcohol. If I am paying attention I can keep my AHI <1, and for long stretches I’ve kept it <0.5 (including 0.0 AHI).

When I got notice from my online CPAP supplier on June 25 that my PRS1 “Pro” CPAPs were recalled, it was a wake up call to me - I needed to pay attention, and I hadn’t been.

I ceased use of my 2010 PRS1 450 (evidence of foam bits) which had been in use at that point of my rotation, usually 10.5cm just so it was obviously different on the overview charts in software from my newer 460 (set at 10cm).   I did not use C-Flex on either PRS1.

My 2013 PRS1 460 has no visible foam issues (even upon disassembly) so I used it up to now.  Very recently I obtained a well-used ResMed Airsense 10 Autoset, disassembled it and soaked and cleaned all parts in the airflow, and started using it asap. 

Mask as of July 1 is Bleep Dreamport.  Prior to that mask was either Swift FX or TAP PAP.  I have a F&P Oracle mask on order, and a Hybrid in the closet that never really fit me.

The ResMed Airsense 10 Autoset has been set to 8-11 cm Auto, 10cm CPAP, and now 10-12cm Auto.  The EPR has been none, 1, or 2 (I hated the feeling in my throat at 2). Humidity ranged from 3-5 (5 was getting droplets in my mask, so backed off to 4).
I have set AutoRamp to 9.8cm so I can tell when it thinks I go to sleep (and then goes to 10cm or higher), and so the AutoSet ignores messy awake/transition events. 

Software used:  OSCAR 1.2.0 on my old MacBook Pro, OS-X.  Imported fresh from saved P-Series folder copies dating back to Fall 2010.  I have 3900 nights to search in OSCAR.  I have the old SleepyHead data as well, which I save for the notes and it includes oximetry from less than a dozen nights back in 2013-15.

Oximetry available.  It is a pain in the finger, but I have used the CMS50D+ oximeter three nights since getting the ResMed machine this summer.

I could figure out the best CPAP setting and set the ResMed to CPAP mode.  But I realize during COVID-19 I ignored the data card (but never my wearing the mask!) and OSA treatment results got worse when I wasn’t looking.  My neck size had expanded with weight gain, and I wasn’t going to the gym.  So I’m thinking I should try APAP to see if I can trust it to get good results no matter if I’m watching or not.  I love CPAP mode otherwise.  I don’t like pressure changes, so I put it on “Soft Response” and a narrow range.

I did a quick spreadsheet (from OSCAR data CSV download) and see that I am mostly dealing with RERA’s and Hypopneas over the course of my time since 2010.  In more than a decade of wearing the mask, my machines have scored:
RERA’s:  24,729
Hypopneas: 13,198
Obstructive Apneas: 3,545
Central Apneas: 364

Note my PRS1 “Pro” CPAP does not record Flow Limitations.  Only the AutoTrial did that on PRS1.  So it has never been something I could pay attention to.

Titration at my study in 2010 was done 8-11cm (Nasal Mask), with 11cm being picked for CPAP as it eliminated snores.  With my doctor’s permission I was able to reduce to 10cm with nasal pillows, and got less air in my belly.

If I’m paying attention, I use 3M micropore tape.  Sometimes doubled up, tripled up, or quadrupled, just because my lips love leaking and drool makes a single layer of tape lose its hold.  For much of COVID time (and TAP PAP use), I did not or could not tape, and leaks could be all over the place.

-SleepyCPAP

[SleepyCPAP]

Here is a month’s Overview of treatment.  Up to July 26 I was using my PRS1 “Pro” 460 which does not record Flow Limitation.  No C-Flex. Bleep mask & 3M tape.

Began use of my used ResMed Airsense 10 Autoset July 27, experimenting with various pressure settings and EPR.  Bleep mask & 3M tape.

   

Here are a couple breath patterns from last night.  One looks like Palatal Prolapse.  Both seem to show my heart beats coming through (PRS1 was less sensitive to those). Note I was on AutoRamp 9.8cm at the beginning of the evening, which is not reflected in the side panel machine info. EPR1. 10-12cm range pressure.

   

   

Feel free to ask for more. Thank you to any who have suggestions.

[SleepyCPAP]

Last night I did not get much sleep (just over 4 hours).  I was awakened by noises, and even though I went back to bed after a trip to the bathroom, I wasn’t falling asleep so after 35 minutes of that I just got up.  

AHI is good, but my breath waves look horrible.  I spent a lot of time struggling with something that looks like palatal prolapse (PP).  Until this past month I don’t think I’d seen this before.

Bleep mask, triple taped (3M micropore, which still leaked), AutoRamp lasted about 15 minutes I think.  Autoset set to “soft” response (though it wasn’t needed much tonight).

   

This PP breathing started right as I fell asleep and lasted a very long time.  Here is a short clip of it
   

A little bit later the waveforms mutated a slight bit. Again a short clip.
   

I see I had a little more normal breathing closer to when I awakened at 3:20.  

Anything else people want to see?  Any comments?

- SleepyCPAP

[SleepyCPAP]

So, since no one is suggesting anything one way or another, I just let my sleep-addled imagination go wild.  Why not?  Ummm… last night was a good reason why not to do that.  

My new F&P Oracle mask arrived, and the nose plugs don’t really fit my nostrils, so I had the bright idea to wear both the Oracle and my Airfit P10 nasal pillows at the same time, connected to a y-pipe adaptor (wye?), held together with cut ends of a CPAP standard hose. So it was a home-made hybrid mask.

Ingenious, except for the fact that it has too much venting.  I spent the night in waxing/waning flow patterns, as my brain couldn’t get my CO2 and O2 balanced.  My SpO2 dropped down to 88 and 86 during the low point of a couple of those troughs.  Mostly RERA’s (16 events) (my used machine must have the updated firmware, as AutoSet didn’t originally do RERA reporting), with Hypopneas next (12), three Obstructives, and one Clear Airway.  Plenty of awakenings, resulting in bathroom breaks. Pressure soaring, resulting in air in my belly.  Large leaks (my guess is all the venting, I don’t think they were mask seal issues).

Set to Full-Face, EPR1, AutoRamp lasted about 10 minutes at the start of bedtime, shorter at the other times.

I had tried a nap in the afternoon, with my TAP PAP mask, which meant I could not seal my lips so lots of leaks then too.  It was not refreshing.

   

[Sleeprider]

I asked you to post this thread because I had observed your respiration flow rate was very uneven, but it is also really amazing on both the inspiratory and expiratory sides with several possibilities. We see a classic double peak inspiratory flow limitation on inspiratory and a classic expiration wave that suggests palatial prolapse or oral expiration. I’m on the phone and want to give this more attention on the laptop, but hope others will chip in. There is a lot going on here.

[SarcasticDave94]

First things need to be first, the leak rate isn't helping. The therapy is blown before it starts. The OSCAR leak chart shows the actual leaks above what's calculated as vent, etc. for ResMed. So this leak rate means you need to address it. It records a Max leak rate of 80.4 and large leak as 76%. Both indictive of nearly free flowing leaking.

I'm not a mouth taper, but I think others mention the Micropore tape probably is leaking, and like a sieve.

The PP and the chart reading otherwise I'll leave to the pros.

[Gideon]

The main problem I see here is Palatal Prolapse.
Read this
https://sites.google.com/view/palatal-prolapse/
This is a non-professional article. Finding anything that deals with the management of PP is difficult to find.
The article mentions that Oral mask pressure therapy bypasses the soft palate altogether. Try an Oral mask such as the Fisher & Paykel Oracle 452 Oral CPAP Mask.
I'd like you to try either this or another oral mask and see how this handles the PP. After that we will tackle whatever is left.

[SleepyCPAP]

Last night I tried the Oracle mask at a lower pressure, straight CPAP.  I suspected from the night before that my body is having trouble regulating CO2 at high pressures on the Oracle, and 7cm seemed more comfortable.  My body eventually took really shallow breaths for 45 minutes or so in the middle of the session, and maybe that was the way to regulate CO2?  I didn’t have my CMSD50+ on last night, so no SpO2.

As a side comment, something may be wrong with this used machine.  It doesn’t take exhale evenly, at least not at my full pressures with the Oracle. It pushes back in pulses of air “hiss… hiss…. Hiss…” through the vent (and I can feel it in my throat and lungs.  As if it doesn’t want me to fully exhale.  I don’t notice it with the Bleep mask.  That is one reason why I didn’t set CPAP to 10cm with the Oracle tonight.  I pulled out my PRS1 to try and the mask didn’t do it on that machine at 10cm, just this used ResMed.

So yes, I’m giving the oral mask a try in order to bypass Palatal Prolapse.  But yuck, it really puts me into untreated AHI range.  Sure, it might seem as if the low pressure (and high FL) would cause this, but the night before the auto mode was pushing closer to 12cm and it was still doing the wax/wane thing with events scoring high at every trough. 

But look at tonight - NO LEAKS.  I took out the anti-asphyxia valve from between the mask and hose, I think that helped a lot.  I seem to have no trouble preventing leaks through my nose, even without plugs!

And the Inspiration Time / Expiration Time are better balanced.

After waking when using the Oracle, I switched back to the Bleep mask in Auto mode. Never slept again in the night.  That’s going to be a problem.

Oracle Mask portion of night:
   

Wax and Wane on Oracle mask (looks like this or worse at high pressure too the night before):
   

Tiny breaths for 45 minutes of calm - look so nice with the oral mask, no Palatal Prolapse:
   


Thanks for replies and suggestions.  
-Sleepy CPAP

[Gideon]

Wax and Wan looks like a recovery breath then all Wan, there is mostly no build up in the breathing it is just there as a full deep breath typical of recovering from a obstructive event.

Your note on your chart says you removed the anti-asphyxia valve, why?

Your detailed breathing looks much better BUT all have flat tops AKA Flow Limited. Flow limits are the big thing left, I really expected that. Your FL 95% stat is .43, we like to see no more than 0.10. The first move is to increase EPR to 3, but you are already there so that leaves 2 options

Increase min pressure to relieve the flow limits, RERAs, and hypopneas or
a new VAuto machine starting with PS=4, I wouldn't be surprised if you needed more.

Which route would you like to go down?

[SleepyCPAP]

Thank you Gideon.

I don’t have access to a VAuto right now, so EPR3 is the best I can do for now.  I can’t have EPR set that high with a pillows mask as it aggravates the Palatal Prolapse, but that isn’t an issue with the Oracle mask.

I took out the valve due to the Oracle’s instructions.  It is not needed if my nose is not plugged.  On the night I had my nostrils plugged it was needed in case the machine went off, but not now when I don’t plug.

I have another alternative.  Since this ResMed fights my exhale, especially at higher pressures, I could go back to my PRS1 460, and set it 10cm-12cm to match my other nights on the ResMed.  I think I have a few nights left of AutoTrial to do that, but of course I have straight CPAP for as long as I want and can set that to 10 or 11.  I hate C-Flex (it seems to be off from my natural timing) but will set it to C-Flex+ at 3 to help with flow.  

I was relieved to get this ResMed machine to get away from the foam fear, but I did inspect the PRS1’s foam (and covered it so it is sealed from the air pathway) and so should be ok.  With the high humidity requirement (according to Oracle’s instructions) I can’t put a bio filter after the humidifier, so we’ll hope my cover-the-foam fix works.

Surprisingly, the really awful AHI didn’t make me feel bad in the night (although my body “rescued” me by getting me up for the bathroom).  So another night of that drama might be OK.  I just need to catch up on sleep.

- SleepyCPAP