[Treatment] Request for help in improving therapy

[Evena]

Hi all,


I'd like to request your help with improving my sleep therapy. I'll start with specific questions, followed by what I think will be relevant information. Any additional help / tips you have are also much appreciated!

Questions:

• What can I do to improve my therapy?
  
• Are my Central Apneas indeed that or is my doctor right that they are probably Obstructive Apneas (see below for a bit more background)
  
• What should / could I discuss with my doctor for her to help me further?
  
• What more information can I provide here so you can help me even better?
  

History / background:
For about 8 years now I've been feeling tired. Mid last year I was (finally) diagnosed with sleep apnea. Sleep research indicated an AHI of about 20. I initially (last year Christmas) got a sleep apnea mouth brace, which reduced tiredness symptoms. During the last sleep research done while wearing this brace my AHI was 13. I still felt sufficiently tired to look further so I got a CPAP machine (see below) in June this year. This does not seem to have helped overly much, as my latest 30-day average AHI is 13.6.

Pressure was initially set at 6 cmH2O (94 days) and was changed to 7 cmH20 15 days ago.

Calls with my doctor are about every 6 weeks; in 4 weeks time I'll have the next one.

I recently read about "positional apnea" and doing the tests I do notice that I can breath less well when tucking my chin / applying pressure to my chin. I've ordered a soft cervical collar to see if that will help, but it is yet to arrive.

OSCAR results
AHI fluctuates. Over the last 30 days:
Average: 13.6
High: 21.7
Low: 7.7
Of these I have maybe 1 or 2 Obstructive Apnea's in the entire night, 15-30% Hypopneas and the rest Clear Airways (see also the provided screenshots).
Since the increase in pressure 15 days ago I'm also seeing a few (0-3) Unclassified Apneas per night, whereas before these were incredibly rare.

My doctor indicated that in my initial sleep research there was no sign of Clear Airways apneas (I don't have access to my own data for that research). I sent her a screenshot from OSCAR and she indicated that she did not believe that my Clear Airways were actually such but were instead Obstructive Apneas). If you can help me to confirm this that would be appreciated.

CPAP machine:
AirSense 10 Autoset
EPR: off
Mode: CPAP
Mask: Nasal mask

About me:
41 years old male, fit (82 kg, 193 cm, BMI and belly circumference well in the green), living at sea level.
I mostly sleep on my side.


Many thanks for reading and for any help you can provide!!


   
   

[Jimmy Lotus]

Hi Evena, and welcome to a friendly and helpful community where you will get great advice for your therapy. 

I'm only a bit more than a month in to CPAP therapy myself and am pretty far from knowledgeable, but here are a couple of hopefully helpful tips about posting your OSCAR data so that the experts here can better advise you:

Turn off both the "Daily Calendar" and "Show Pie Chart" under the "View" tab at the top of OSCAR. That will provide more information in the left sidebar.

I'll attach a recent (and my best so far!) screenshot that may help illustrate what I'm referring to. Our screenshots will be different as you're using a 1080p display whereas I use a 1440p.

ETA: The most important charts/info to show seem to be Event Flags, Flow Rate, Pressure, Leak Rate, and Flow Limit, if I recall correctly.

[Old Mike]

What sort of sleep test did you do? The most basic ones can't differentiate between OA's and CA's as far as I know (key determinant is whether or not you wore belts while sleeping). You should insist on getting a copy of the sleep study. CPAP treatment is known to induce a certain amount of central apnea in some patients, but nothing on this scale. As regards the accuracy of the machine in determine whether they are OA's, CA's or unclassified (the machine isn't sure whether OA or CA), the technology used sends rapid pulses of vibratory pressure to the airway and, depending on the response, determines whether it is closed or not. I reckon it is probably 80% accurate, perhaps even better. So my guess is that you probably have mostly central sleep apnea and require a different machine (ASV or Bilevel). Others here are more knowledgeable on such machines.

[Sleeprider]

Evena, if you will turn off the monthly calendar and pie-chart in the left column, we will be able to see a lot more useful information. Also, please include one full-night overview along with the closeups. At this point I'm kind of conflicted whether your events are actually central or a high flow limit obstruction, and your charts as formatted are missing a lot of information I need for that. I would guess this is mostly central, and your background diagnostic study may not have identified this issue. CPAP will not resolve central apnea, and you may have to start from scratch with a proper clinical PSG sleep study and diagnosis. Your CPAP therapy is failing badly, so I don't know that I would wait until the next routine follow-up to consult with the doctor.

[Evena]

Thanks for the tips! I'll repost some screenshots with the new settings.

And I'm only slightly envious of your "perfect score", but it also gives me hope that something like this is possible! :-)

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What sort of sleep test did you do? [...] You should insist on getting a copy of the sleep study. [...] So my guess is that you probably have mostly central sleep apnea and require a different machine (ASV or Bilevel). [...]

The test had a device that was stuck to my chest and something around my finger to measure oxygen saturation.

I'll ask for a copy of the sleep study data. And I'll also discuss whether I should get a different machine.

Thanks for your input, much appreciated!

[Evena]

Evena, if you will turn off the monthly calendar and pie-chart in the left column, we will be able to see a lot more useful information. Also, please include one full-night overview along with the closeups.  At this point I'm kind of conflicted whether your events are actually central or a high flow limit obstruction, and your charts as formatted are missing a lot of information I need for that.  I would guess this is mostly central, and your background diagnostic study may not have identified this issue.  CPAP will not resolve central apnea, and you may have to start from scratch with a proper clinical PSG sleep study and diagnosis.  Your CPAP therapy is failing badly, so I don't know that I would wait until the next routine follow-up to consult with the doctor.

Hi Sleeprider,

Thanks for taking a look at this. I'm attaching newscreenshots with the information as asked. If you can tell me anything more based on this I'd very much appreciate it!

       

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And with two more screenshots for a different day:

       

[Sleeprider]

Those are much better charts with the kind of information we need. You are using a fixed pressure of 6.0 with no EPR. Most events are being flagged as central and hypopnea, however most of the breathing shows obstructive flow limitation as indicated by a long inspiration time with restricted peak flow. I think we need to trial a higher pressure and add in EPR to see how you respond. If it works, we win, if not, we're not going to lose much. Let's try putting the machine in Autoset mode, minimum pressure 7.0, maximum pressure 10.0 with EPR on Full-Time at setting 2.
Mode: Autoset
Minimum Pressure: 7.0
Maximum Pressure: 10.0
EPR: On Full-Time
EPR Setting: 2

[Evena]

Thank you so much for your input! I've been in contact with my doctor and we agreed to try the settings you suggested and I had my first night sleep with them. With an AHI a bit over 10, quite a bit below my long-run average, I'm hopeful that this is a step in the right direction!

[Sleeprider]

I'll look forward to seeing your chart results and see where the improvements happened and where we can still find some optimization.

[Evena]

Third night on the new settings and I got an AHI of 5.1, my lowest since I started therapy. I'm hoping that the downward trend will continue, so maybe further optimization isn't necessary right now? If I start to plateau again I'll be sure to post some further images though!

And again thank you so much for your help!