Wife tried machine, lots of flow limitations?!

[YouTakeMyBreathAway]

My wife mentioned she still felt tired waking up this morning (after 10 hours of sleep...), I assume this is from the remaining flow limitations.

Interestingly, it doesn't seem like the flow limitations go away when the machine ramps up its pressure, or rather it took a long time at that elevated pressure before they went away.

I assume the best next step is to set a higher minimum pressure (which she already did in the morning, setting it to 10.0 - 15.0)

[Sleeprider]

Let her try your Vauto with EPAP min 5.0, PS 4, max pressure 12.0 EPAP. Can you handle the swap?

[YouTakeMyBreathAway]

Oh man, I bet that'll be extra rough for me.

She now got scheduled for an official CPAP titration and is waiting on the machine to take home for 5 days. Given her AHI is low I assume there's no way she'd qualify for a BiPAP even if the increased PS would help her?

Tonight we tried a higher minimum pressure (11 - 15) and overall the stats looked the same, similar amount of flow limitations. I did notice that her respiration rate and tidal volume have been considerably more stable looking at the graph.

She did mention breathing out has become more difficult at the higher pressure.

[Sleeprider]

I really don't worry too much with 95% flow limitation below 0.1, and hers is 0.06-0.07, and there was no change in that moving to higher pressure. It's really more important to listen to the subjective comfort levels she is communicating to you. You are absolutely right that CPAP will be found effective, and it is. We could be looking at issues that will self-resolve as she adapts and becomes more comfortable with the machine. We can observe a significant improvement from her first night and objectively, her best results and comfort were with the 10-12 pressure range. We never did see minimum pressures at 8 or 9 cm. She started at 5-6 and I think went straight to 10 cm minimum. I would suggest going back and looking at the settings history and relating that to comfort and results, then perhaps backing off the minimum pressure a bit.

[YouTakeMyBreathAway]

She changed the settings to 6-12, I'll recommend trying minimum of 8.

She mentions she still feels just as tired as before. I wonder if the flow limitations are pointing to UARS?

It seems weird that they don't seem to respond at all to pressure... is this common? Does this point to her airways just generally being very narrow but not collapsing?

In her sleep study, they identified an AHI of 8.3 all being hypopneas and 0.4/h RERAs. I wonder if her current results are actually meaningfully different from without the machine?

[Sleeprider]

I don't see a problem with the lower pressure she is proposing. Let her try it, but make the minimum 7.0 to leave room for EPR 3. This is HER therapy not yours. You can help to look at the results and if you observe obstruction, suggest the solution is to use a higher minimum pressure.

[YouTakeMyBreathAway]

Makes sense on minimum 7 for EPR.

One other thing; her AHI is good at all pressures, making me wonder if the sleep study could have been flawed and somehow incorrectly flagged all those 8 hypopneas/h? How accurate is hypopnea measurement through the nasal cannulas? Is the threshold maybe different and what it picked up was just the flow limitations she still has?

[Sleeprider]

The sleep study flow rate is a reliable measure of respiratory flow, but many people are intolerant of the clinical sleep setting and do not have a "normal" night. Hypopnea is a fairly significant event, right behind apnea. When hypopnea are present, flow limitation and the associated respiratory event related arousal (RERA) are almost always present as well. Insurance is only concerned with apnea and hypopnea to provide a measure of medical necessity, but RERA can be a debilitating sleep breathing disorder that causes fatigue and poor sleep architecture. As you know, we can have relatively low AHI event rates but still have poor sleep. CPAP, especially with EPR addresses that problem insurance and many doctors ignore.

[YouTakeMyBreathAway]

Her RERAs were scored at just 0.4/h, which is the other reason I was wondering if she may not actually have an issue w/ her breathing?

[Sleeprider]

She showed a high REM AHI and RDI but maintained a consistently high SpO2. I seriously doubt there is a pulmonary or breathing issue, and would not attempt to diagnose it, if I thought one was present. Give it time.