Treatment thread for robbob2112 wife - need help

[robbob2112]

Hi All, 

I've been using my asv for a number of months and it has been a real help.  My wife was given a Resmed Airsense 11.  It is set in CPAP mode with 14cm.

They sent her home from the mask fit with a P10.... They never hooked it up to the machine and she can't stand the thing.  Hates having to keep her mouth closed.  And the machine was used with 149 hours on it.  I took it back and swapped it for her the next day and demanded a SD card which they were reluctant to give.

I had her try several of my mask styles to see if she can stand any of them and we settled on the F30i.

Still she can't stand the pressure being constant at her.  I turned the pressure down to 10cm and still is to much.

So, here is where I need advice - What should I do to make things work for her.  The overnight sleep study is attached.  There was a major problem with the study IMO.  They ran out of suplemental oxygen and kept boosting pressure until her O2 level maxed out.  She is on 2L O2 at night anyways.



Seems to me I need to flip it to apap or apap for her and possibly lower the pressure to some reasonable number then adjust from there depending on what the Oscar graphs show.  But I wanted to get an expert opinion on it from the crowd here.

Thanks for any help

Robert

[Sleeprider]

Based on the sleep test results you submitted, I'm glad she is using supplemental oxygen. You should obtain a recording oximeter to see if 2-L/min is sufficient. Unfortunately, many doctors don't know that supplemental oxygen is very diluted by CPAP therapy and it takes more oxygen to obtain a sufficient fraction of inspired oxygen (FiO2) to meet the needs of an individual. Using a cannula to deliver oxygen to the nose is very different from using an oxygen bleed to a CPAP circuit. Please read our wiki on this topic. https://www.apneaboard.com/wiki/index.ph..._with_CPAP

Your wife showed mainly obstructive hypopnea and probably has considerable upper airway flow resistance or inspiratory flow limitation. It would help to see the CPAP results in Oscar to give you advise on settings. I suspect she can use much lower pressure and that the use of EPR will be pivotal to her comfort and effectiveness.

[robbob2112]

.  Unfortunately, many doctors don't know that supplemental oxygen is very diluted by CPAP therapy and it takes more oxygen to obtain a sufficient fraction of inspired oxygen (FiO2) to meet the needs of an individual. 

Your wife showed mainly obstructive hypopnea and probably has considerable upper airway flow resistance or inspiratory flow limitation.  It would help to see the CPAP results in Oscar to give you advise on settings.  I suspect she can use much lower pressure and that the use of EPR will be pivotal to her comfort and effectiveness.

Thanks sleeprider,


We both wear an O2ring at night so I will have the data once I can get her to wear the cpap more than an hour.  Right now she flat out rejects it and throws the mask off in under an hour.  In my case I went from SpO2 in high 80s to low 90s pre-ASV to 95+ all the time with.  I am using a climateline oxy verse a bleed fitting with the O2 set on 2L continous.  

I may have to fiddle, if hers doesn’t behave similarly.  The climatelineoxy fitting is on the end of the elbow verse at a right angle to flow.  In theory that should create a low pressure just in front of the port.  I should be able to do the same with an elbow on a standard hose for her.  Of course in theory the flow should be a bit of a low pressure with it at a right angle, but not as much.  Time to break out the physics book on fluid dynamics or ask an AI.

I plan to turn on apap for her at 10cm and see how a night's data looks. What epr would you suggest.

I.e. please suggest something because she would have already taken it back and I only have a couple of chances to get her to use it.

Robert

[Sleeprider]

Rob I assume your wife was not on oxygen during her sleep test. What does her SpO2 look like with oxygen on a cannula?

[robbob2112]

On canula she averages low 90s upper 80s at night with a pulse dose set to 4. On the cpap it will be 2L continuous or I'll have to bring up the larger concentrator. Without the O2 she quickly bottoms out in the 70s from gradually shallower breathing.  That from me watching her sleep.  She snores lightly and is all over the bed in all positions.

We use a phillips simplygo so it does pulse to 8 or continuous to 2L.

No oxygen during the test.

[Sleeprider]

Let's try to optimize the PAP therapy and keep the O2 bleed as high as possible with what you have. If there is cause for concern, I'll probably refer you to her doctor for advise on increasing FiO2. Do you know the reason for the very low perfusion levels? It seems to go beyond adequate ventilation or she should have been prescribed bilevel to improve her ventilation rate or end expiratory pressure. I get the impression she is being treated for simple obstructive sleep disordered breathing, but her issues are more complex, not unlike your own.

[robbob2112]

We have an appointment next week to take to a pumanologist for a full workup.  She was a 25 year smoker and no longer does the last 10 years, so we suspect some lung damage. We will take the results of the sleep study with us for him to look at as well.

If he says we need a bilevel the DME WILL trade at no cost.

You are correct, they are treating simple OSA.

[Sleeprider]

First a critique of the CPAP titration.  Your wife had better results at 11 cm than 14, however, the lack of a linear relationship of events to pressure suggests the titration actually produce more or less random results.   At 10 cm she experienced 10 events in 13 minutes for an AHI of 46.7, then at 11 cm no events were recorded in 21.7 minutes.  At 12 cm AHI was 6.6, 13-cm 45.1, 14 cm 7.7, 15 cm 0.0, 16 cm 1.5 and events rise again at 17 and 18 cm.  CPAP titration produce random results because CPAP is not the solution to hypopnea and inspiratory flow limitation, bilevel is.  With pressure support, your wife will likely experience a much lower event rate at lower pressure.  Let's look at a bilevel titration protocol:



Your wife never experienced obstructive apnea, even without CPAP, so we can start with a low EPAP 4.0 and IPAP 8.0 and observe if hypopnea are resolved. If OA occur, EPAP and IPAP are increased If hypopnea is present, the protocol increases IPAP or pressure support.  An additional benefit of bilevel is that effective therapy is provided to an individual with restrictive lung diseases at lower pressure, and improved ventilation can be ensured.  CPAP does not have this capability.  You should request the pulmonologist refer your wife for titration with bilevel, or better yet, simply prescribe bilevel based on her needs for better ventilation and the apparently random results in CPAP titration.  You know how the self-titration game works and can provide assurance that following the protocol above, it will be possible to titrate an effective therapy. You can stipulate that you will not exceed PS 6.0 without physician consultation. The finhdings of the pulmonologist will be interesting. If he diagnoses a restrictive lung condition, the mechanical advantage of bilevel therapy should be obvious in off-loading part of the respiratory effort to the machine. This is how hypopnea is resolved instead of brute-force pressure from CPAP which only stents the airway and does not provide a respiratory assist.