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Please help.... - Printable Version

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Please help.... - Lann - 12-20-2023

English is not my first language, and I have never lived in any English-speaking countries (I am currently living in China).

I'm still learning, so apologize for any confusion and difficulties in reading due to my poor English skills.

We are feeling desperate as there isn't much information available on how to adjust these machines on the Chinese internet. The seller of these machines and doctors haven't been helpful either. (Believe it or not, the term "sleep apnea" is quite new around here, and some doctors don't even know what a CPAP machine is.)

Here's the story:

My grandmother was diagnosed with sleep apnea a month ago, and the doctor said she needed a CPAP machine and recommended the Fisher & Paykel SleepStyle.

We bought it, used it for a couple of days, and her AHI was through the roof. Adjusting the pressure as the doctor instructed didn't change that.

Then we switched to the ResMed AirCurve 10 Vauto, which was good at first using the VPAPauto mode. Then it went up to 39.
The seller told us to switch to the CPAP mode, we did, and the numbers went down again (5.45, 1.94). But two days after, it was 16.15

I checked her sleep reports, and there's something I find a little odd: the pressure was pretty stable during her sleep, a plain straight line on the graph, while I saw other people's reports where the lines were bouncing up and down. Does that mean the machine was not responding to her apnea?

I have attached the reports from the previous nights. Please help; any advice would be appreciated.
(I forgot to mention that she has dementia, and she would take off the mask or shut down the machine power during the night if nobody's watching, so we only managed to get her to use it for 3-5 hours per night.)

RE: Please help.... - PeaceLoveAndPizza - 12-20-2023

Your English is wonderful, no apologies necessary. 

That is a difficult situation, but thankfully you are there to help. Sorry the medical folks are not being much help, we’ll do our best to do what we can.

If the sleep report is in English, it would be helpful to see it. Be sure to redact any personal information before posting. If not 

If not in English, a few questions.

Did the sleep report say anything about central sleep apnoea’s? 
What pressure did they use?
What was the breakdown by event type? Hypopnoea’s? Obstructive? RERA? Central?

The current settings are not optimised for your grandmother. It is quite possible this is the incorrect machine for her if the main issue is central apnoea’s. If CA’s then a ASV would be the proper machine. For now, we can work with the Vauto.

If you are open to experimenting a bit, put her setting's to EPAP min 4, IPAP max 15, PS 4 full-time, no ramp, trigger very high. This will allow the machine to respond to events buy increasing/decreasing pressure. It should also be more comfortable for her so hopefully she can keep the mask on longer.

This will give us a baseline to start from and we can help adjust things from there. See if she can tolerate it for a few nights and post some OSCAR charts.

RE: Please help.... - CPAPfriend - 12-20-2023

As PeaceLoveAndPizza mentioned, the sleep report is relevant here. The apneas are central, so the machine of choice is ASV. If the apneas were central on the sleep study, then the doctor made a mistake.

I would just mention that I think having a PS of 4cm like that will likely worsen her central-apnea count.

RE: Please help.... - Lann - 12-20-2023

Thank you for your help, we truely appreciate it.

Yes, the report from the hospital is in English. It was daunting when we first saw it, so many acronyms, and I am not a medical student. 

I will post it here.

The report mentions 'CSR probable.' I had no idea what that ment until I searched it online. What I found is that we might need a ASV for her.

But we contacted the seller a few days ago, and they said that ASV is for patients with Chronic Obstructive Pulmonary Disease(some sort of lung disease I believe, it literally has the character 'lung' in Chinese). 

For my grandmother, they suggested a BiPAP machine with ST mode is enough for her condition.

They gave us Resmed Lumis 150 VPAP ST-A to try for a few nights. We used it yesterday, but the result wasn't ideal, she felt even more uncomfortable and only used it for an hour. I tried to import the date to OSCAR but it keeps crashing whenever I try.

I will adjust the Vauto as you suggested and see how it goes.

Thanks again, we are really gretaful.

RE: Please help.... - Lann - 12-20-2023

Thank you for your reply.

We didn't know that our settings were bad, and the seller just keeps telling us to raise the pressure.

The seller said the BiPAP machine with ST mode is good enough for her, and the price of an ASV will cost four times higher than a BiPAP if we really want it.

We can't afford that at the moment, a BiPAP machine has already hit us hard financially. But if it's truly what she needs we'll try to figure something out.

RE: Please help.... - Lann - 12-21-2023

I am sorry, I'm a bit confused, what should I do with the PS setting?

RE: Please help.... - PeaceLoveAndPizza - 12-21-2023

For now, start with PS on 4. Once we know how she reacts to that we can adjust it from there.

RE: Please help.... - Gideon - 12-21-2023

The issue is, as stated above, Central Apneas.
Based on the zoomed image showing individual breaths, these are real central apneas.
The question now becomes what is, it is not the cause.  Not the cause is what we expect to learn from your sleep study.  IF they were minimal on the sleep study, plus your report of changing therapy and they improve it is very likely that they are Treatment Emergent Central Apneas (TECA).

What causes these (assuming TECA)?
Our breathing, simply put, is driven by the need to remove CO2 and other byproducts.  It is not driven by our need for oxygen.
The use of a CPAP, along with higher pressures and a higher differential between inhale and exhale, which is called pressure relief, EPR, Pressure Support (PS), will increase the 'efficiency' of your breathing resulting in the flushing of more CO2 than would happen without these things.  When CO2 levels go below your 'apneic threshold' you will stop breathing showing a central apnea until your CO2 levels go above your apneic threshold.  
Further a loop-gain situation can occur which causes over shooting both high and low resulting in the sine wave patter you show in your zoomed image.  This is not the only thing that can cause this pattern though this cause is quite common.

SO a question on health, especially heart and lung health in addition to this apnea.
Does your grandmother have a serious heart condition, Congestive Heart Failure can often cause this pattern.  
While ASV, IVAPS, and BiLevels with backup can and do treat central apneas, the actual root cause is important for selecting which device in best for an individual.  Other than heart and lung issues, does your grandmother have any neuromuscular issues?

Central Apnea can, and often is, inconsistent, we call this consistently inconsistent.
CPAP mode, and BiLevels without backup (the ability to initiated a timed breath at a defined rate) such as the VAuto are programmed to ignore and do nothing for a central apnea.  Thus settings used should be designed to minimize the occurrence of central apneas.  Do note that the actions that will minimize central apneas will also increase obstructive apnea.  This is expected and within reason is acceptable.  The end goal without a device specific to central apnea is to achieve a balance between central and obstructive apnea.

Until we have further info try the following

VAuto
Min EPAP =8
Max IPAP =12
PS=1
TRIGGER= High (This has helped many by initiating a spontaneous breath on a smaller change.)  Note: internationally not all VAuto's have this setting.  Does yours?


Sorry I just saw your sleep study.

Item of concern on the sleep study.  CSR PROBABLE

CSR is Chyene Stokes Respiration, the difference between CSR and TECA is cause. (yes there is a bigger difference but bear with me).  CSR mostly results from congestive heart failure!  Please eliminate this with her doctors.

Otherwise is see your issue as TECA.

Good thing. TECA typically goes away or significantly diminishes over time of several months as the body adapts.
I'm not a fan of using ASV for treating TECA so in that I agree with the doctors BUT ASV is not for COPD as ASV relies of the average breathing volume and specifically a moving average and as such ASV is inappropriate for typical COPD.  IVAPS, where a target volume can be set would be much more appropriate for that.  

See the below from the wiki https://www.apneaboard.com/wiki/index.php?title=Prescription_-_CPAP_-_APAP_-_BIPAP do note that neither ASV nor ASV Auto are intended to treat COPD

CPAP choice to treat OSA, CA, obstructive or pulmonary restriction
The Auto CPAP such as the AirSense 10 AutoSet is typically the initial machine of choice for treatment of obstructive apnea and hypopnea
Just to clarify The VAUTO, ASV, S, and the ST are all BiLevel machines for treating three different conditions, they are NOT interchangeable. They are not a choice between them to treat a single condition.
They should be chosen to treat the specific condition that the user has, Here are the various CPAP machines and what they are designed/intended to treat
This info is from the ResMed Sleep Lab Titration Guide

  • CPAP (continuous positive airway pressure) Fixed pressure delivered with optional expiratory pressure relief (EPR). It Treats OSA

  • AutoSet/APAP (automatic positive airway pressure) Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas. It treats OSA

  • AutoSet for Her/APAP Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas along with an increased sensitivity to each flow-limited breath, providing a more comfortable therapy for women. Increases sensitivity to each flow-limited breath, providing a more comfortable therapy for women (OK for men too). It Treats OSA

  • VAuto Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas; Pressure Support (PS) is fixed throughout the night and can be set by the clinician. It Treats OSA, non-compliant OSA

  • S (Spontaneous) Senses when the patient is inhaling and exhaling, and supplies appropriate pressures accordingly. Both treatment pressures are preset: inspiration (IPAP) and expiration (EPAP). It treats Non-compliant OSA and COPD

  • ST (Spontaneous/Timed) Augments any breaths initiated by the patient, but also supplies additional breaths if the breath rate falls below the clinician’s set “backup” respiratory rate. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions

  • T (Timed) Supplies a clinician-set respiratory rate and inspiratory/expiratory time, regardless of patient effort. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions

  • iVAPS (intelligent Volume-Assured Pressure Support) Maintains a preset target alveolar minute ventilation by monitoring delivered ventilation, adjusting the pressure support and automatically providing an intelligent backup breath. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions

  • ASV (adaptive servo-ventilation) Targets the patient’s minute ventilation, continually learning the patient’s breathing pattern and instantly responding to any changes. It treats Central or mixed apneas, complex sleep apnea, Periodic Breathing (PB)

  • ASVAuto Provides an ASV algorithm plus expiratory positive airway pressure (EPAP) that automatically responds on the patient’s next breath to flow limitation, snore and obstructive sleep apneas. It Treats Central or mixed apneas, complex sleep apnea, Periodic Breathing (PB)

  • PAC (Pressure Assist Control, also known as Pressure Control) The inspiration time is preset in the PAC mode; there is no spontaneous/flow cycling. Inspiration can be triggered by the patient when respiratory rate is above a preset value, or delivered at a set time at the backup rate. It Treats Neuromuscular disease (NMD), pediatric patients



RE: Please help.... - Lann - 12-22-2023

I'm sorry, I didn't see your reply in time.
I adjusted the PS to 3 last night as I was concerned about what CPAPfriend mentioned that setting PS to 4 could worsen her CA.

The rest of settings were adjusted accordingly and the result from last night was quite good, her AHI was 1.32
We could still try 4 if you think is necessary.

I've attached the report, if there are further adjustments needed, please let me know.

Thank you for everything.

RE: Please help.... - Lann - 12-22-2023

Wow, thank you for taking the time to write this, it's very informative.

My grandmother does have heart disease, CHF, Atrial Fibrillation, and she also has Parkinson's disease.(Should've mentioned these earlier, sorry.) The doctor says her heart failure isn't severe, though. Do you think we should get her an ASV considering her CSR?

We used these settings yesterday, and her AHI was 1.32

VPAPauto
Min EPAP =  4
Max IPAP = 15
PS = 3
Trigger Very high

I'll attach the report as well.

We'll try your settings tonight.

Thank you, I deeply appreciate the detailed explanation. I've learned a lot.