mallar's therapy thread

[mallar]

Had my CPAP machine for a little less than 3 months. It's been challenging, but I'm seeing benefits. My persistent issue is that I'm waking up multiple times a night, it seems like every hour. My CA's are also quite high, and clustered.

EPR 2

I'm not sure what's causing me to wake up. Last night's (3/16/24) AHI was under 4, but I woke up many times, and felt worse than the 10 AHI night. (

Can anybody see what's going on? If I'm reading the forums correctly, these clustered CA's can be related to a sleeping position issue?

[mallar]

For reference: I am adding my sleep study results below. I don't have the raw data at this time. It was an at home sleep study.


Recording Profile:
The patient was monitored for a total time of 403 minutes.
Respiratory Profile:
There are 5 obstructive apnea, 6 central apneas, 0 mixed apneas.
There are 87 obstructive hypopneas for a AHI index of 15 .
Baseline O2 Sat 98% and lowest O2 Sat 74 %; less than 90% 19 minutes.
Cardiac Profile:
Minimum pulse: 45 bpm
Maximum pulse: 211 bpm
Average pulse: 53 bpm

[Jay51]

EPR can either be set at 0, 1, 2, or 3.  Yours is set at 2.  The higher the EPR, usually the higher the CA's can be.  Thus lowering EPR could lower CA's.  But, EPR works well to tame flow limitations.  A balancing act for sure.  You can experiment with lower EPR if you want to.  There are treatment emergent CA's - it takes some time for the body to adjust to the better breathing from xpap; so some CA's can happen early in therapy.  But most people overcome these in a few weeks or month or so.  

Even though it was a home sleep test, your max heart rate was recorded at 211.  This is abnormal.  It was probably an artifact (error) since it was a home sleep study.  You should keep an eye on this in the future though (and mention it to your PCP).  

Your SPO2 gets pretty low also.  But, again, it was a home study, and many errors can occur with a home study (bad finger sensor, movement causing errors, etc.).  You might want to mention the low SPO2 on this study to your PCP also.  It wouldn't hurt to simply give a copy of this to your PCP to look at.  That is what I did:  I took a home study 1st and gave the results to my PCP.  She then ordered a polysomnography because of my poor results.

[mallar]

Thanks Jay for the response.

When I first went to the provider, she suggested this is treatment emergent CA and that it would go away over time. It's been about 3 months on CPAP and I haven't really seen a decrease in the CA AHI, or more importantly a decrease in the multiple overnight wakeups. I was also told this could be simple insomnia now, as my OSA is now successfully treated by PAP and my body has merely gotten used to waking up a lot over time. I am open to adjusting the EPR down if needed.

RE: sleep study. Heart rate I'm inclined to believe is an artifact. The O2 I am going to examine on the CPAP at least with a Wellue Checkme. What would the benefit of a further polysomnography study be?

Questions:

• Could this still be considered treatment emergent central apnea after 3 months?
  
• With the clustering, does this suggest any positional issues? Could this perhaps be addressed with a cervical collar? I have a pretty flat pillow.
  

In the end, I just want to sleep through the night! I can't remember the last time I did.

[Jay51]

Actually, you don't have to pursue a polysomnography.  You can get great suggestions here to optimize your therapy.  

That is a tough question about still being treatment emergent after 3 months.  When I look at your charts, I see the CA's lining up with mask leaks.  By solving mask leaks, you might reduce your CA's significantly.  Here are some tips to reduce mask leaks.  Mask Primer

If the tips don't work, you can try lowering EPR.  You can also try a soft cervical collar if lowering the EPR doesn't work.  Not bad therapy IMO; and several tweaks to try to get better optimized.

[mallar]

What's causing my sleep arousals? Can these arousals be reduced if the machine were titrated to my body?

I was never given an overnight titration study. Just given broad settings, a 10-minute how-to, and told "good luck!". I'm about to see the provider again, who seems to be amenable to ordering titration if my sleep and centrals aren't better. Attached are some recent nights. Some observations:

• I believe my CA's are based in disruptions to my sleep.
  
• I think I'm sensitive to arousing from pressure changes. Before I'm fully asleep, I'm often startled awake as the APAP reaches therapeutic pressures. (I don't have ramp enabled)
  
• I believe I'm started at too low a pressure.
  
• I might benefit(?) from a smaller range of pressures, or a steady pressure (+EPR)
  
• A change in mask to a hybrid full face has helped reduce leaks, and slightly reduced my CA's 
  
• (I'm trying out the F40, and am cautiously optimistic it'll help further -- not enough nights on it to feel confident in the charts yet) 
  

Do these charts support my observations? Will a tighter setting profile address my arousals?

---

stats for the second day

[BoxcarPete]

If you're pretty comfortable at 8 with EPR 2 and think that you are sensitive to being awoken by pressure changes, there's no reason you can't try CPAP 8 for a night or two. Just keep in mind that you may be awoken by a sleep breathing anomaly that your machine is also responding to, so it could be a misattributed correlation. Trying flat pressure for a handful of nights would be a good way to find out about it.

[mallar]

Thanks Boxcar for your response. I am definitely considering putting it on CPAP -- at 8 as that's been my 95% for about a month now.

What are you referring to when you say "sleep breathing anomaly"? Are these anomalies something other than apnea, hypopnea, RERA and Cheyne-Stokes? How would I see them in the charting?

[BoxcarPete]

Yes, the most common trigger for a resmed machine to increase pressure is called "Flow Limitation" and it represents a detection of a partial blockage or some other reason for a poorly-shaped breath waveform. These don't get flags, but instead have their own graph on a resmed machine where every few breaths are given a score from 0-100, with 0 being the best and 100 being near-apnea.

[Jay51]

Great suggestions by Pete.  In your OSCAR I see a median inspiration very close to your expiration times (both about 2.5 or so).  Also, your median respiratory rate is a tad less than 12.  From all the literature I have read, 12 to 20 or so seems to be the average respiratory rate for sleep.  

It seems like you are encountering some resistance somewhere along your respiratory tract.  You take long, slow breaths.  This possibly could be causing the wake ups IMO.  The treatment is usually increasing EPR; but we can't do that since you already have a lot of CA's.  Increasing EPR can increase CA's due to increased ventilation and co2 washout.  

Try Pete's suggestion.  There are machines that can provide both more pressure support if needed and a back up rate if necessary also.  We will try to optimize your current machine and see if that is good enough or not for you.