Switching from CPAP to APAP advice

[SleepyCPAP]

Here are breathing patterns from last night.

The first one is weird. I’m asleep at that point, and the cycle continues like this for a long time. It is not quite like Pugsy’s chart, though closest to the expiratory mouth breathing example (which can’t be, as my mouth was freshly taped and not leaking at that point in the night). I note that I’m at (or near) the maximum pressure for the evening, but those are NOT nicely rounded curves.

The next one is later in the evening and looks more normal for me. But it looks like the pressure is too low to make the breaths rounded. A little leak might be part of that. That 3M tape is starting to lose it here (I don’t think my Bleep Dreamports were leaking, they didn’t seem to be in the morning).

Early Sleep Breath Screen Shot 2021-08-03 am.png (184.71 KiB) Viewed 806 times

Later night breath Screen Shot 2021-08-03 am.png (186.39 KiB) Viewed 806 times

[SleepyCPAP]

Maybe this is related to my early sleep breathing last night? Inspiratory palatal collapse?
“Palatal prolapse as a signature of expiratory flow limitation and inspiratory palatal collapse in patients with obstructive sleep apnoea”
https://pubmed.ncbi.nlm.nih.gov/29444914/

Palatial Prolapse breath patterns.png (434.57 KiB) Viewed 803 times

From google:

There is no standard treatment for palatal prolapse. CPAP is not considered effective due to the one-way valve operation of the soft palate and be aggravating the but may still be required concurrently to treat other collapse sites. Paradoxically, CPAP may even aggravate the collapse due to the improved air flow. Gabapentin significantly increased the mean AHI[16] possibly through myorelaxation and may have similar effect on palatal prolapse. Pressure reduction on exhalation: EPR, C-Flex or Bi-Level PAP reinforces the expiratory flow, pushing the palate like a sail in the wind and is likely to worsen the prolapse. Mandibular Advancement Splints (MAS) oral appliances were not effective[8][9].

So is EPR making this worse? I will have to look at non-EPR nights (on this ResMed, and on nights of PRS1) to see when this shows up.

Edited again to mention a thread here on this forum:
https://www.cpaptalk.com/viewtopic.php?t=171982

[Pugsy]

I’m ignoring the events in the first 12 minutes - those are sleep transition events. It is clear the machine wants to ramp up for them though!

Remember the machine doesn't know if we are asleep or not. It only measures air flow and responds to what it senses.
My dream machine would be a machine that knows if we are really asleep or not. But it doesn't exist....yet.

If I’ve got that continued flattening curve / Flow Limitation through the night, why isn’t APAP keeping up my pressure? Is it because I’m in soft response mode, with the slow rise and decent of pressure adjustment? Again I am sorry I don’t have a “For Her” model, as that algorithm is more sensitive to flow issues.

I don't know about soft response but it isn't the same as the special algorithm available in the for Her model machine.
We can't take a regular AutoSet and use the soft response and make it turn into what is available on the For Her model in that special algorithm.

As to why it doesn't keep the pressure up....we simply don't know and have no way of knowing all the criteria and little bitty details of the ResMed auto adjusting algorithm but we would assume that if it doesn't keep the pressure up then you don't meet whatever is needed to keep the pressure up....at least per the machine algorithm.

How much of this is related to soft vs standard response? Dunno because ResMed typically doesn't really go into a lot of detail as to what soft vs standard response actually does.

I guess you need more experiments in standard response to see if it changes anything.

[yrnkrn]

Maybe this is related to my early sleep breathing last night? Inspiratory palatal collapse?
“Palatal prolapse as a signature of expiratory flow limitation and inspiratory palatal collapse in patients with obstructive sleep apnoea”
https://pubmed.ncbi.nlm.nih.gov/29444914/

First pattern indeed looks like palatal prolapse. The topic isn't well researched, everything I could find summarized here: https://sites.google.com/view/palatal-prolapse/.
Palatal prolapse isn't treatable by PAP, but the other issues in the graphs are.

[palerider]

The next one is later in the evening and looks more normal for me. But it looks like the pressure is too low to make the breaths rounded.

You're getting a really strong cardioballistic return in that one, so that's going to blow good analysis of the breath shapes out of the water, ie with that much variation in the flow because of your heart beat, and some of those happening during the inhalation... it makes it really hard to evaluate.

[SleepyCPAP]

Last night was nearly useless. I had tried a nap in the late afternoon, with my Hybrid mask (in case of palatal prolapse). That leaked and kept me from getting to sleep, so it felt like 20 minutes wasted in my day (that’s when I gave up). In the evening I got to bed late, and I think I remember my sleep being disturbed, and finally I had to get up for the bathroom (it seems related to a pressure change and a bit of palatal prolapse leading to sleep arousal). I went back to bed for an hour after that, but never slept. Is this just “one of those nights” or maybe “this isn’t working”? I don’t know.

I do notice that the CA’s have a twin event, echo. One is twin CA’s, which I will show here. The other CA’s had palatal prolapse occur soon (but different distances) after.

I was leaking a lot. This time it seems from my Bleep dreamports. I’d prepped as well as usual before I put them on, but there was a definite air passageway when I was taking them off. Anytime you see the end of a leak period on my screenshot, I had a brief awakening/arousal from whatever stage evident in big breaths after. I won’t bother to include them, but that gives a little sense of how many awakenings.

What I’m going to do:
1. Stay at these settings at least another night. Try to get used to pressure changes and fix leaks.
2. I put an oral mask on order (F&P Oracle). I need something else when nasal pillows are not working, for instance with palatal prolapse. My Hybrid mask just doesn’t fit right.
3. Get to bed earlier as a habit.
4. Catch up on life/work stuff and not take time to do morning screen shots to post daily in this thread. A pause and reallocation of that time. I’m really just in a “get used to it” phase right now.

Here is the “Sleep Time” overview (notice I don’t say “whole night” as I disabled the nap session and the 1-hour not-sleeping session). The AHI on the other charts changes depending on whether the 1-hour machine time was added for the average or not when I did the screenshot, there were no events during the hour I’ve turned off.

Sleep time Screen Shot 2021-08-04 am.png (201.87 KiB) Viewed 751 times

OA Twin Lead up Screen Shot 2021-08-04 am.png (199.29 KiB) Viewed 751 times

OA twins Screen Shot 2021-08-04 am.png (190.42 KiB) Viewed 751 times

[SleepyCPAP]

Here are typical breathing patterns when asleep - one during large leak time, one not.

Typical breath in leak Screen Shot 2021-08-04 am.png (189.38 KiB) Viewed 750 times

Breaths Non Leak Screen Shot 2021-08-04 am.png (190.88 KiB) Viewed 750 times

Short obvious palatal prolapse (PP) example below (there were several incidences like this one, but no long stretches in the night, unlike the night before). I looked through the past week+ of daily wave forms. Short periods of this are evident, even on the PRS1 recently. No examples showed up in the sampling I did of other nights over the past years. This (PP) may be a new thing, and because it showed up on the PRS1 in CPAP mode (no flex), it is not related to the machine (though EPR might have been contributing the night before last, it didn’t have the same effect last night so far as I can see).

Palatal Prolapse following OA Screen Shot 2021-08-04 am.png (193.39 KiB) Viewed 750 times

[SleepyCPAP]

Quick update:

I tried the Oracle (oral) mask. I tried it with my nose plugged, and without. I tried it teamed up with an AirFit P-10 so that both my nose and mouth got pressure, but the leak rate from the vents was too much. I do not like it Sam-I-Am, I do not like the oral mask, I do not like it here, I do not like it there. But I’ll keep it because I took to it better than my Hybrid full-face, and I need something on hand whenever a nasal pillows mask can’t be used.

I also found the ResMed fought me so I could not exhale completely. I don’t get that machine issue with the Bleep mask. I temporarily tried my recalled PRS1 “Pro” in AutoTrial mode at the same setting (10-12cm, no flex) and the Oracle wasn’t being fought (and not the Bleep of course).

I went back to the Bleep mask on the ResMed 10 Autoset. That does not solve expiratory Palatal Prolapse (PP), and indeed I had the worst night ever (since before titration in 2010) recently. Sleepyhead (which does better with my CMS50+ oximeter downloads) told me “You had an AHI… which is considered horrible, please consult your doctor.” (Emphasis SleepyHead, one of those quirks that I loved JediMark put in there, but it isn’t in OSCAR). Here is a three minute snapshot of that trainwreck of a session of PP:

OSCAR 1.2.0 Palatal Prolapse Apneas galore

Screen Shot 2021-08-23 at 9.50.08 AM.png (219.92 KiB) Viewed 712 times

My primary care Doctor saw my note and is requesting an appointment for me with a new Sleep Doctor’s office (see other thread where I ask what to ask the doctor).

I’ve now turned off EPR (it was on that night, despite what OSCAR says) and I’m using a wedge pillow. I’m getting much better results with the wedge if I position my head exactly right (even excellent results, 0.15 AHI last night and no bathroom break, but other nights not quite right still).

[SleepyCPAP]

Hi all, a quick update:

Wedge pillow, cervical collar, and doing straight CPAP at various levels for the past weeks. Sometimes better.

Paid for Lanky Lefty (Jason) to go over my OSCAR data with me online. Helpful insights and suggestions. One suggestion was to stick with CPAP, rather than the 10cm-12cm range, but try different pressures for a few nights to get the sweet spot. I was doing just as well (or better) at 9cm, 10cm (my usual) wasn’t great, 11cm not not different on average from 9cm, and 12cm felt like it was stretching my lungs.

Finally got an appointment at the Sleep Doctor’s office. Explained everything, and provided handouts. Basic result: go back on APAP and raise your range 1cm, then come back in a month. Any AHI of 5 and below is considered treated, and you’ve only been above 5 sometimes. Maybe you would be less anxious if you didn’t check your data. Sorry, we can’t read more than 30 days off your SD card. We can’t compare to the recalled machine you have, because we can’t get our Respironics software to work.

I’ve now had well over a year’s worth of Obstructive Apneas since August 1. Two months time. I pointed that out.

In the meantime I’ve just had a heart attack. Never had any indication before, and I’m normal BMI and physically active and not old enough to have had this! Cardiologist noted I was paying attention to my sleep apnea and said “that’s good, that can stress the heart.” Whereas at sleep doctor’s office it was said “well your oxygen desaturations aren’t that bad, so high AHI isn’t hurting your heart.”

Here is a close up on a night with Cervical Collar, taped mouth, wedge pillow. Straight CPAP 10cm, but I’d done 8,9,10,11, and 12cm and still get this expiratory Palatal Prolapse (and random nights where everything looks fine).
:

Prolapse Five OAs in Five Minutes Screen Shot 2021-09-19.png (203.82 KiB) Viewed 496 times

A “bad” July night at 10.6cm for comparison (borrowed ResMed AirCurve 10 VAuto). Poorly taped mouth. No wedge, no cervical collar:

A bad AHI July night for comparison.png (190.45 KiB) Viewed 496 times

Oooo, look at the improvement at 11-13cm APAP last night. It took eight minutes to be as bad as CPAP at 10cm (5 minutes) in the first example. At this rate of “just raise 1cm and see me in a month” I’ll be back to July’s results in a few months. (Snark)

Five OAs in 10 minutes at 11-13cm APAP.png (221.96 KiB) Viewed 496 times

So for right now I’m following the sleep doctor’s orders, so I have enough nights at APAP 11-13cm to prove this needs more than that.

My heart aches (literally and figuratively).

- SleepyCPAP