[Treatment] New User Seeks Guidance

[Sleeper396]

Sleeper,

I, as Ratchick does, am wondering about your sleeping oxygen saturation percentages.

I am not at all an expert here, I'm just a beginner. I am a long time CPAP user, but just a few months ago, with help here, i have started to improve my PAP treatment. My treatment reports look similar to yours. I have significantly reduced the obstructive apneas that I have, but I still have clear airway apneas, like the ones on your reports. In my case, they are sometimes isolated, irregular occurrences, usually a larger breath followed by an apnea. The issue with all of them is if they cause oxygen de-saturation's or arousals. For me, the isolated events don't often do that, but when they are part of a pattern of cyclical breathing, I have depressed oxygen saturation during those periods. And, for me, I can correlate those periods of low oxygen saturation with poor sleep quality. (And for me, that can often occur when there are no flagged events, too.)

For me, using the pulse oximeter all of the time I'm using the cpap is very informative.

I hope that helps.

Thanks, Jadazu. My pulse oximeter should arrive today and I will be monitoring beginning tonight. I am concerned about that exact fact, and wonder what can be done should O2 levels look unsatisfactory.  What have you done?  Your suggestion is appreciated.

[Sleeper396]

As a follow up to the excellent feedback, I am posting the last 2 nights Oscar reports.  Last night 7/1/21 report, you will see even more frequent wakeups. I started a new mask last night, a ResMed AirTouch N20 (nasal mask).  I had to change back to my full face mask in the middle of the night, due to some discomfort. Will need a few nights to see if I can tolerate the nasal mask, as I am very sensitive in the nose area. You can see large leaks on the nasal mask. When I went to the full face mask (about 2:15 AM) the leaks resolved. My questions are twofold:

What is an acceptable leak level? Oscar shows large leak of 7.6% last night. How would that interfere with therapy and AHI's? Please explain the Leak Rate graph and what it means. I had 11 Large Leak events. In the opinion of the experts, does that mean that the nasal mask is not working for me, and I either have to use a chin strap or tape, which BTW, I do not think that I am prepared to do, or return to full face mask, which did not create leaks for me. I am already using a cervical collar, but that did not appear to work for the nasal mask. I think that I'd rather "suffer" with a full face mask than tape or add a chin strap. 

Second question.  Note the 2 nights. My centrals are running 75% of my AHI, and my AHI is averaging 4 for last week, and appears to be improving. Since centrals are below a 3 index, if my O2 levels are OK (which I will start monitoring tonight), would the only important further indicator of successful therapy be how I feel the next day? Right now, I am crashing in the evening, and I believe that is due to the broken sleep cycle perhaps caused by centrals. So my goal is to continue to manage down the centrals, as my OSA seems to be under control.  Do I have this right?  Just doing a reality check on where I am trying to go.  

As a final comment, I cannot tell you how happy I am to be surrounded by the people on this board.  You have all been terrific! The collaborative approach to working on each persons concerns is amazing. The organization and management of this board is outstanding.

[Jadazu]

  ...As a final comment, I cannot tell you how happy I am to be surrounded by the people on this board.  You have all been terrific! The collaborative approach to working on each persons concerns is amazing. The organization and management of this board is outstanding.

Firstly, those are my feelings, too. I've had over 20 years of (ineffective) cpap treatment, supervised by three specialist physicians, and I have learned more here in three months than I learned in 20 years from the physicians. And, with the help I've received here, I have significantly improved my therapy in ways that 20 years of physicians' care didn't do.

Sleeper,

Re what can be done about oxygen levels, I am just starting in the care of a new physician, and have very recent PSG results, and this is his concern as well as mine. So this is yet to be determined.

I just had the follow-up visit to see the results of my recent PSG, and I learned a few things, after being shown the strip charts.

   

Isolated apneas, like this one above, were not scored as events when there was no associated brain waves arousal or disturbance.

Hypoxia, like below, is a *big* problem. The first 30 minutes of my sleeping was with restricted or impeded breathing, without apneas, and with an extended hypoxia. (This is my second night at a lower air pressure than I have previously been using. This was the new doctor's new prescription from two days ago. I've sent him a note this morning to ask about it...)

   

The rhythmic breathing, like below, is a concern too.

   

So for me, the oximeter is important.

Large leaks do compromise your therapy. That is the indication that the machine is operating outside of the capacity within which the machine air flow measurements are accurate, and within which the therapy algorithms work correctly. I don't have the experience to say much about the leak graph. I do have problems with mouth leakage, and I was also trying mouth taping. Also, I had to try several cervical collars to find the 'right' size one, for me, the tallest height and the smallest circumference. With a good fit, it is as effective as a chinstrap.

Re the clear airway apneas, yes they can fragment your sleep, and diminish your sleep quality. (In my recent PSG, I had an AHI under 1, but an arousal per hour index of nearly 10, and disrupted sleep patterns.)

good luck,
Jim

[Jadazu]

Also, to try to answer your question: The leak rate graph is a measurement of the amount of air flow in excess of the design leak rate of the mask. If all of the tidal air you were breathing vented through the mask vents, and none leaked out through your mouth or under the mask seal, the leak rate would be zero.

[Sleeper396]

So interesting, Jim.  Thanks for sharing your data and experiences on O2 and breathing issues. I wish you all the best.

[SarcasticDave94]

For myself, on a ResMed, the leaks that show in OSCAR should be about 10 max. ResMed has what I call a redline, in part literally you can have a red line show on the leaks chart at 24. As you approach the redline at 24 therapy efficiency drops, and I believe that accuracy drops accordingly. The higher the leak, the more efficiency and accuracy drop.

Back to the mask. On the nasal mask, you're saying it causes discomfort or pain, correct? If yes, then at least one aspect on that particular mask is wrong.

You have fit, which is cushion and headgear size. These must be selected to fit properly. Have you tried a larger or smaller cushion to see if leaks are better controlled?

Next is adjustment of straps. It covers how much tension applied and how to adjust them. Some masks have several steps to adjust properly. Typical tension should be just enough to minimize and control leaks. If you can't minimize and control leaks without pain, stop and move to another size, model, or type of mask.

Mask type needs to be considered. Pillows mask should be first chosen. These have the least area needing to seal, and go against the nares but not in the nostrils. Nasal cradle or nasal mask is next. Some cradle the lower nose, others look like a smaller full face but go over the nose only. Then we have full face and hybrids. Regular full face seal over the nasal bridge and over your mouth. Hybrid seals over the mouth as usual but use a cradle under the nose for the top.

No matter what combo you use, stop and start over on your choice of mask if pain or discomfort are encountered. On any mask, lie back on the bed and hold the mask in place, noting how much tension is needed for your fingers to hold it there under PAP pressure. Now duplicate that feel with the straps. Sitting up to adjust will throw things off, you must adjust in a sleeping position. Facial features change while lying down and it'll make mask fit change.

[Sleeper396]

You have fit, which is cushion and headgear size. These must be selected to fit properly. Have you tried a larger or smaller cushion to see if leaks are better controlled?

Next is adjustment of straps. It covers how much tension applied and how to adjust them. Some masks have several steps to adjust properly. Typical tension should be just enough to minimize and control leaks. If you can't minimize and control leaks without pain, stop and move to another size, model, or type of mask.

Hi Dave, 

Yes, I tried multiple sizes on the new nasal mask. The small was too tight, but the medium is a perfect fit for me. I will take your advice on the method of adjustments for this evening. I may have been doing something wrong.  I have tried 4 different nasal masks so far and chucked them all due to nose discomfort. I always had sensitivity issues for my nose in particular, and I have silicone issues as well; but I am hopeful that I can persevere.  The masks that I am using are ResMed Memory Foam (Air Touch) products, so the cushioning appears to be better for my purposes. Thanks for the mask primer -- so helpful.

[Sleeper396]

. . .I'd love to see what your oxygen levels are doing during the night, even with so few events. If only because I managed to have a massive O2 drop last night just from less-than-ideal breathing without actually triggering much in the way of events.

Good morning to all, 

This is a short progress update. Any thoughts would be welcomed. 

As Ratchick suggested (along with Jadazu), I have been monitoring my oxygen levels with SleepU (which apears to be a really good device). Last 2 nights of monitoring O2 levels were fine for me.  Average level of 96; lowest level of 92. O2 drops > 4% -- 1 per night. So, O2 is under control at this time. I had my best night of sleep session time (over 3 hours uninterrupted) the other night. 

Generally, my sessions are 1.5 to 1.75 hours each (interrupted by bathroom breaks), and strung together to create total sleep time of 6.5 hours. (Dave sent me an example of his similarly fragmented patterns at the early stages of his therapy, so I'm hoping for improvement).  Also, I am napping in the evening in front of TV for up to one hour. So, total sleep time may push 7 hours, but not the way I want it. I don't want to nap, but cannot help but fall asleep after dinner. I use my APAP for the nap time also. Would love to see longer sessions adding up to a night of 7+ hours of sleep, with no napping in the evening. 

Centrals are 75% of my events, with AHI's now down below 3 (except last night 3.5), so Central Index is regularly in the 2 range (with what I believe is daily SWJ upon wakeup).  I've sort of settled on the Full Face Mask, and have gotten used to it. The AirTouch F20 (memory foam) seems to work for me.  No leaks and relative comfort.  This is my 6th mask, and the only one that I can tolerate so far. (I haven't given up on a nasal mask yet, but am struggling with it -- dry mouth and breathing gaps).  

So, that's my update.  Any suggestions would be greatly appreciated as always. Last night's Oscar is attached.

[Sleeper396]

. . . and one further note relating to my most recent night (last night).

I had a bad night with Centrals almost approaching a 5 index  (85% of my apnea events).  I had 3 wakeups, and fragmented sleep, as usual. Please take a look at last night, and factor it into any suggestions.  Is this the basis for an ASV machine?  I'll go a month from now and hit my doctor up.  If it continues, I'll consider paying for it myself, if insurance will not cover it. I'm wondering if the wakeups and nocturia could be due to the heavier amount of Centrals. The duration for a few centrals were up to 20 seconds on occasion (see Oscar close up for one example of that). Please comment on my progress. Thanks.

[Sleeper396]

As a further reminder, on my laboratory sleep study this past month, I had Central Apneas along with others, displayed as follows:

Sleep disordered breathing was more severe on back (156 minutes on back) with an AHI for supine position period of 35.5; Overall AHI for entire sleep study was 14.0;  (Note: a home sleep study done the previous month --- almost entirely supine, showed AHI of 40, with significant Oxygen Desaturation). 
Lab study showed 71 total apnea events -- consisting of 28 OSA's, 23 Centrals; 0 mixed apneas; and 20 Hypopneas; with maximum duration of 41 seconds.
Respiratory Disturbance Index; (RDI) was 31.3 events per hour.
Sleep Saturation: Avg. 95%; Minimum 78%; 6.3 minutes below 88%;
Arousals: Arousal Index 18.9/hour; 96 arousals; 88 of those arousals (91%) were RERA.

So, now my Centrals appear to have taken over my apnea problems. (see last night Oscar on above comments). I feel that I am getting closer to demanding an ASV, but want to be on strong ground. Please give me the benefit of your thinking on the best way to approach my doctor.