Personal CPAP Machines in PACU of Uncertain Benefit

Morbius wrote:

49er wrote:Since many people like BS have just as bad apneas in an upright position...

This is an undocumented assumption, but I shall let OD respond as I had inadvertently and rudely interfered with her response above.

You can interrupt me any time. Your answers are much more detailed than mine. As far as the head of bed position, a 30 - 45 degree angle helps to support respiratory effort by allowing your lungs to fill with less work. Now if this makes a difference in your obstructions, I can't say.

OkyDoky wrote:

Morbius wrote:

49er wrote:Since many people like BS have just as bad apneas in an upright position...

This is an undocumented assumption, but I shall let OD respond as I had inadvertently and rudely interfered with her response above.

You can interrupt me any time. Your answers are much more detailed than mine. As far as the head of bed position, a 30 - 45 degree angle helps to support respiratory effort by allowing your lungs to fill with less work. Now if this makes a difference in your obstructions, I can't say.

Thanks, that makes sense.

49er

chunkyfrog wrote:Once again we see the most disturbing medical attitude of all beginning to infect the laity.
This is the attitude that one size fits all, therefore what fits Peter will fit Paul.
Lazy medicine, because we are all different, and divergence is a crime, punishable by death.

DramaRana.

OkyDoky wrote:Your answers are much more detailed than mine.

How about:

For the brief monitored period that OSA, or patients at risk for OSA, time is spend on the specific position of the head and neck to maintain airway patency:

Placing the head in the "sniffing position" (lower cervical flexion, upper cervical extension with full extension of head on neck) increases longitudinal tension on the upper airway and decreases its collapsibility. Displacing the mandible forwards pulls the tongue forward and increases the caliber of the retrolingual airway and the retropalatal airway as the soft palate is also displaced forwards because it is coupled to the tongue via the fauces. Simply lifting the chin with mouth closure can also be effective in increasing pharyngeal dimensions by increasing longitudinal tension in the pharyngeal muscles and anterior neck structures. This action increases the anteroposterior distance between tongue and posterior pharyngeal wall and counteracts the tendency to collapse.

OkyDoky wrote:As far as the head of bed position, a 30 - 45 degree angle helps to support respiratory effort by allowing your lungs to fill with less work. Now if this makes a difference in your obstructions, I can't say.

It should, as caudal traction on the upper airway relieves pressure (especially in the obese) on the pharyngeal structures. See Schwartz, split_city, etc. discussed previously.

Morbius wrote:Sorry sweetie. The (a) risk in the PACU is respiratory depression/arrest, and all the CPAP in the world won't help that.

Wouldn't the normal concerns about an untreated apnea patient still apply despite the extra risk of respiratory depression/arrest?

I can't comment on the medical/technical pros and cons, not being in that field. But when I had a colonoscopy (which in these parts generally involves propofol), they encouraged me to bring my equipment for my time in recovery. Unfortunately, the DME didn't deliver the equipment in time. Solution? No sedation (my preference anyway), which clearly wouldn't work for most surgeries, including the one I'm going to have to have on my leg. So I'm following this discussion with interest.

All I can say is, before I was diagnosed, the best sleep I had in years was in the hospital after I had a pulmonary embolism (which may well have been dear OSA's fault to begin with) - because I could crank the head of the bed up and they had me on oxygen . First thing I did when I got home was order the highest bed wedge (about 30 degrees) that I could find.

Sadly, even with that and xPAP, I feel like I'm underbreathing when asleep. So I'm having an oximetry study next week. When I finally have surgery, I don't know what is going to happen with my airway in recovery. I'm quite worried about it.

I stayed at Hopkins inpatient in 2013 and was not allowed to use my own machine because they didn't have the available staff to test it. Their machine had no humidifier and I didn't tolerate it very long. Needless to say, it was a pretty miserable stay. I avoid Hopkins, if possible. I've never had a good experience there. UMMC is far better in nearly every way.

Darth Lady wrote:I can't comment on the medical/technical pros and cons, not being in that field. But when I had a colonoscopy (which in these parts generally involves propofol), they encouraged me to bring my equipment for my time in recovery. Unfortunately, the DME didn't deliver the equipment in time. Solution? No sedation (my preference anyway), which clearly wouldn't work for most surgeries, including the one I'm going to have to have on my leg. So I'm following this discussion with interest.

All I can say is, before I was diagnosed, the best sleep I had in years was in the hospital after I had a pulmonary embolism (which may well have been dear OSA's fault to begin with) - because I could crank the head of the bed up and they had me on oxygen . First thing I did when I got home was order the highest bed wedge (about 30 degrees) that I could find.

Sadly, even with that and xPAP, I feel like I'm underbreathing when asleep. So I'm having an oximetry study next week. When I finally have surgery, I don't know what is going to happen with my airway in recovery. I'm quite worried about it.

Darth Lady,

I totally understand your feelings. Like you, I definitely plan on having a colonoscopy without sedation. I would rather put up with discomfort than deal with med side effects which I am very susceptible to.

Unfortunately, GA is the one game in town for a septoplasty. Some ENTs will use TIA but for various reasons, I prefer GA although to be honest, I would answer none of the above.

By the way, I just tested positioning myself in a chair to simulate the half reclining position and I felt like I was breathing much better with the Fit Life Full Face Mask although I had to bump the pressure up from my normal 12/8 prescription to 14/10. I was concerned about the mask leaking but it sealed fine in that position.

Anyway, I find it very encouraging about being placed in the semi upright position after surgery if this is any indication as to how things will go. Regarding your concerns, can you ask to be placed all the way up after surgery if that seems to work best for you? I definitely hear your concerns.

Out of curiosity, I am going to try sleeping like this tonight to see what happens. If I don't sleep well, no harm, no foul since it isn't like that has been a regular occurrence for me.

Anyway, I think Oky Doky for mentioning the half reclining position because if she hadn't, it wouldn't have occurred to me to test this out.

49er,
I had a septoplasty with conscious sedation. Didn't feel or hear a thing. No matter what anesthesia you have you will be in a semi upright position as a choke prevention...yes, a little blood might trickle down your throat at first. Mine last about half an hour. I was told to sleep upright. I used a bed sitting pillow for that. I was advised not to use cpap for about 2 weeks.

It was the best surgery I ever had. I finally could breath through my nose!! Also made using cpap easier. Best of luck.

webbie73 wrote:49er,
I had a septoplasty with conscious sedation. Didn't feel or hear a thing. No matter what anesthesia you have you will be in a semi upright position as a choke prevention...yes, a little blood might trickle down your throat at first. Mine last about half an hour. I was told to sleep upright. I used a bed sitting pillow for that. I was advised not to use cpap for about 2 weeks.

It was the best surgery I ever had. I finally could breath through my nose!! Also made using cpap easier. Best of luck.

Hi Webbie,

Did you feel the conscious sedation had less side effects than general anesthesia? If that is the case, then I will ask the anesthesiologist about this when I meet with him/her. ENT didn't mention about having a choice so who knows.

Regarding you not using cpap for 2 weeks, I am just struck at how different each ENT is on this. Current one would have forbidden it with a nasal mask for a week but said with the Full Face Fit Life, I can start using it immediately because it isn't touching the nasal area.

Glad it worked for you. I can hardly wait to have the same results and there is no doubt in my mind that this ENT will do a great job.

I didn't have a septoplasty, but I did have a turbinate reduction and resection of severe scar tissue of unknown origin. It was so bad I couldn't breathe out of one nostril at all and only about 40% of the other one. It came on so slowly that I didn't notice until an ENT I was seeing for an ear issue asked why I was breathing from my mouth all of the time. She told me I had severe polyps and wanted to do surgery. I didn't have much confidence in her, so I went for a 2nd opinion. That ENT told me that it wasn't polyps (which can be treated with nasal spray, etc) but the worst scar tissue he'd ever seen, and transferred me to a specialist ENT (they do exist) who did the surgery.

He wanted me on CPAP from day one. I wanted to bring it to in/out surgery, but they said I didn't need to, as the surgery was to take 15 minutes. It took longer because my scar tissue was just that bad. The anesthesiologist (who I didn't like) demanded they give me insulin before I go to surgery because my blood sugar was up. Yes, it was up due to stress, and not being able to take my meds (oral meds - not on insulin - blood sugar well controlled). He said he wouldn't work on me until they did it, so my ENT relented. Never again. I woke up to them shoving cheerios down my throat. They wouldn't tell me why. My GP told me the only logical explanation was that my blood sugar crashed (surprise). Now I have damage to my throat that they want to do more surgery on, but I have declined, as having throat surgery on my complex airway scares the daylights out of me.

They gave me a shot of pain meds in the in/out surgery suite, and my O2 sats dropped way low, and I had to go on an oxygen mask. About 2 hours later, they let me go home, with a note that they wanted me to be on CPAP even for naps. My nose was full of packing for the first 24 hours, and then I had splints for 8 weeks. My only "no-no's" were to make sure I used humidification every day, and I'm not allowed to use nasal pillows - ever.

funky-rat wrote:I didn't have a septoplasty, but I did have a turbinate reduction and resection of severe scar tissue of unknown origin. It was so bad I couldn't breathe out of one nostril at all and only about 40% of the other one. It came on so slowly that I didn't notice until an ENT I was seeing for an ear issue asked why I was breathing from my mouth all of the time. She told me I had severe polyps and wanted to do surgery. I didn't have much confidence in her, so I went for a 2nd opinion. That ENT told me that it wasn't polyps (which can be treated with nasal spray, etc) but the worst scar tissue he'd ever seen, and transferred me to a specialist ENT (they do exist) who did the surgery.

He wanted me on CPAP from day one. I wanted to bring it to in/out surgery, but they said I didn't need to, as the surgery was to take 15 minutes. It took longer because my scar tissue was just that bad. The anesthesiologist (who I didn't like) demanded they give me insulin before I go to surgery because my blood sugar was up. Yes, it was up due to stress, and not being able to take my meds (oral meds - not on insulin - blood sugar well controlled). He said he wouldn't work on me until they did it, so my ENT relented. Never again. I woke up to them shoving cheerios down my throat. They wouldn't tell me why. My GP told me the only logical explanation was that my blood sugar crashed (surprise). Now I have damage to my throat that they want to do more surgery on, but I have declined, as having throat surgery on my complex airway scares the daylights out of me.

They gave me a shot of pain meds in the in/out surgery suite, and my O2 sats dropped way low, and I had to go on an oxygen mask. About 2 hours later, they let me go home, with a note that they wanted me to be on CPAP even for naps. My nose was full of packing for the first 24 hours, and then I had splints for 8 weeks. My only "no-no's" were to make sure I used humidification every day, and I'm not allowed to use nasal pillows - ever.

HI funky-rat,

I am so sorry for your horrific experiences. Why couldn't you take your oral meds with a sip of water on the day of surgery as people are instructed with most meds? Was there some reason you were given that you weren't allowed to?

49er

funky-rat wrote:I woke up to them shoving cheerios down my throat. They wouldn't tell me why. My GP told me the only logical explanation was that my blood sugar crashed (surprise). Now I have damage to my throat that they want to do more surgery on, but I have declined, as having throat surgery on my complex airway scares the daylights out of me.

Dumb. Dumb. Dumb. Every parent of a diabetic infant knows that you use frosting in a squeeze tube to raise blood sugar on someone who is not able to cooperate with eating. Cheap, simple, widely available, dissolves instantly in the mouth and the saliva starts digesting the sugar even before it's swallowed.

(Which I suppose is unfortunately on topic to the assertion that medical staff aren't smart enough to use cpap machines...)

cathyf wrote: (Which I suppose is unfortunately on topic to the assertion that medical staff aren't smart enough to use cpap machines...)

Totally untrue and inflammatory remark.
I'm not going to comment on personal experiences but I want to see if I can explain some respiratory risks in PACU and why CPAP usually does not address these problems. The respiratory depression/arrest that can occur has a neurological basis rather than obstructive. So while the effects of anesthesia and pain control narcotics are being balanced your apnea is usually not pressure related (obstructive) but neurological. So with most personal CPAP machines they do not respond unless you are breathing, meaning you may still be awakened by alarms and the nurse instructing you to take deep breathes. This stimulation is actually a part of your recovery. With cardiac monitoring, respiratory function monitoring, etc. in PACU, it will become evident whether you will be able to maintain respiratory functioning without assistance.

I understand surgery is scary, I've been there and don't like giving up control that general anesthesia requires. But in life I have come to understand that sometimes I have to turn it over because I can't fix it myself.
Now if you talk with your anesthesiologist and he agrees to provide CPAP in the PACU it may provide you comfort but probably will not address the main cause of the apnea until the effects of anesthesia have worn off.

Once you are transfered to your room and being allowed to sleep, CPAP may be very beneficial.

This is my understanding from my perspective and I'm not telling you where to take your stand. I don't pretend to have all the answers, just a few. I do wish you the best care and recovery for your surgeries.