Forced to sleep on back now ASV ineffective

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
SeekSleep
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Forced to sleep on back now ASV ineffective

Post by SeekSleep » Thu Apr 05, 2018 12:17 pm

Thanks in part to help from these forums a few years back, I've been successfully treating my Sleep Apnea for 5 or so years, average AHI of under 2. To keep things low, I had to train myself not to sleep on my back as things weren't working with any decent settings then. Unfortunately, I've recently had surgery to remove part of my colon, and have a colostomy bag for probably the next year and have found I can't sleep in any position but on my back. Now my best night has had an AHI in the mid 20s with some nights as high as mid 70's. My ReMed S9 vpap adapt according to sleepyhead is flagging primarily UAs as the issue, with occasional Hypopneas just for kicks. The settings I have been using are:

Mode: ASV, EPAP 7.0 PS 3.0-15.0 (cmH2O) This worked great for me for years.

When I started sleeping on my back and my treatment became ineffective I switched modes to ASV Auto, and worked up to EPAP 11, PS 4-15, MAX IPAP 25. Looking at sleepyhead my EPAP is now running at 15 most of the time and IPAP is maxing out a lot.

To control mask leaks for my Mirage Quattro full face I've tightened it down to where I'm getting nose sores and having to wear moleskin across my nose. Even tightened down, although the machine isn't recording leaks all that bad, the mask often squeals enough to wake me up.

My thoughts are that when on my back, the pressures needed to keep my airway open just aren't practical. Anyone got any inputs as to what other options might be out there for me.

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jnk...
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Re: Forced to sleep on back now ASV ineffective

Post by jnk... » Thu Apr 05, 2018 12:29 pm

It is counterintuitive, but as the ResMed dudes say . . .
That mask, like the majority of modern full-face masks, needs to be relatively loose on the face for it to inflate enough to make a good seal for comfort and for not waking you up. Use a tube hanger if necessary to keep the hose from pulling on the mask.

Don't assume the unclassified apneas and hypopneas are fully obstructive; there may be a central component to them or they may be centrals entirely, as related to the increased pressure needed to prevent obstruction when you are on your back.
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Pugsy
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Re: Forced to sleep on back now ASV ineffective

Post by Pugsy » Thu Apr 05, 2018 12:35 pm

How recent was the colon surgery and are you taking any different medication....like pain pills or muscle relaxers?

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Re: Forced to sleep on back now ASV ineffective

Post by raisedfist » Thu Apr 05, 2018 1:17 pm

Would it help to use a wedge pillow, or sleep in a recliner?

What kind of leaks are we talking about? Maybe try the F&P Simplus - I find it holds up to high pressures. Or nasal pillows if you can keep your mouth shut.

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Re: Forced to sleep on back now ASV ineffective

Post by SeekSleep » Thu Apr 05, 2018 3:40 pm

Regarding the Surgery, I had Two Heart Stents installed on 11 March, a simple overnight stay in hospital and only stayed because went in with chest pains and couldn't get angiogram and stents till next morning. Unfortunately, the evening of 12 March developed extreme stomach pain, turned out to be Perforated Diverticulitis, emergency surgery approximately 2am on the 13th. Not currently on muscle relaxants, or pain pills of any sorts. Blood pressure meds, cholesterol meds, blood thinners.

I'm aware the mask shouldn't be too tight, and I've normally used a looser fit. Unfortunately, when my machine ramps up to 25 it's not uncommon for the seal to start leaking/vibrating against my skin and making a loud sound that wakes up me and my wife.

We have a king bed, adjustable to many different settings. Last night I tried a variation of mostly reclined bed, and put my machine back to the settings I've been using just to see if anything changed as I've tweaked my settings a couple times since I got home. Attached is the Sleepyhead report from last night, AHI of 75. I'm also attaching a copy of the best night I've been able to get so far, and what the settings were. Unfortunately, I woke up several times then. I keep my machine in a dresser drawer and use the auto function to turn it on and off. Being an ASV machine, it sometimes fights me right as I'm drifting off to sleep so I've got ramp function set. I might try turning that off to see if it helps any if I'm going to be waking up several times a night.

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Re: Forced to sleep on back now ASV ineffective

Post by Pugsy » Thu Apr 05, 2018 3:44 pm

Hmmmm....ugly for sure.

What's the highest EPAP minimum that you have tried and the results?

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Re: Forced to sleep on back now ASV ineffective

Post by SeekSleep » Thu Apr 05, 2018 4:07 pm

I thought I had set it for 12, but it appears I only went up to 11.6 Also, I set the IPAP higher than the machine will go, while the machine lets me dial in higher numbers, it appears to top out at 25. Unfortunately, unlike years ago when I took a little time to research prior to making any small adjustments, I've forgotten what I learned back then to where now I'm guilty of dial changing without taking the time to figure out what I'm doing first.

Attached is the printout from from my highest EPAP setting night. As you can see, I took the mask off for a bit, which is something I've done a few times since the surgery, but hadn't really even done when I first started wearing this thing. If left on my own I'd probably just try maxing it out at EPAP 15 next and see what happens, but I've finally decided to reach out to those wiser than me first. My other issue is that It looks like I've got to find a new sleep doctor. Mine moved on, my insurance changed the first of the year, and the recommended new sleep doctor doesn't take my insurance. You've got to love how that works. I'm now to the point where I'll have to carry a planner just to keep track of the different specialists I've got to see, and more importantly probably all the assorted drugs.

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Re: Forced to sleep on back now ASV ineffective

Post by Pugsy » Thu Apr 05, 2018 4:46 pm

Can you zoom in on the time frame at 23:00 and only have it show 4 to 5 minutes total?
Omit snore graph and include mask pressure graph please (so the 2 pressure graphs). I am wanting to see the flow rate zoomed in and what the pressure was doing when the whatever event was flagged.

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Re: Forced to sleep on back now ASV ineffective

Post by SeekSleep » Thu Apr 05, 2018 5:08 pm

Here is the zoomed in data. Thanks for taking the time to look

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Re: Forced to sleep on back now ASV ineffective

Post by Pugsy » Thu Apr 05, 2018 5:21 pm

One more screen shot please. Same 23:00 spot but this time a 10 minute window.
I don't know what is going on or if anything can be done to fix it but I need to reach out to a couple of people I know and ask for their input. One is a member here and the other sometimes stops by..and he may or may not get my note to him tonight.

The machine is working its little butt off for sure and it can't go higher than 25 on IPAP.
I do wonder what would happen if it could go higher than 15 EPAP....and would it doing so maybe make centrals not be adequately taken care of because not much room for needed PS jump.
But at this point...maybe centrals would be the lessor of the 2 evils.
I wonder what would happen if you changed over to regular ASV mode and used 14 EPAP with PS min of 3 and max of whatever it would let you with EPAP at 14.
I mean...it's bad now even with your "best" report. My gut says you need more EPAP than you can get in this mode ....my gut might be wrong. What we are seeing here is really unusual and its the only thing I can think of at the moment.

Let me shoot out a couple of messages to a couple of people that might have more ideas or thoughts.
In the meantime...get me that 10 minute window of same approx time frame.

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Re: Forced to sleep on back now ASV ineffective

Post by SeekSleep » Thu Apr 05, 2018 5:57 pm

That the machine is working hard is very obvious when you're trying to sleep with it. On the plus side, it just did it's job without causing me any issues for so long that until recently it had become just routine, something I never thought much about. We retired last summer, spent months on the road traveling in a fifth wheel, and my numbers always looked good, be us desert or seaside, sea level or 10000 feet. I just breathed the way the machine wanted, or it let me know who was boss. Now the poor little guy is getting frustrated as I don't seem to be cooperating.

Here is a capture from around 2300 and another from the bad section around 4:30am

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Re: Forced to sleep on back now ASV ineffective

Post by palerider » Thu Apr 05, 2018 7:59 pm

For any more shots, could you please move the mask pressure chart up under the flow, and move the pressure chart down out of the way?

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Re: Forced to sleep on back now ASV ineffective

Post by Pugsy » Thu Apr 05, 2018 11:38 pm

How about adding a soft cervical collar to help hold the chin up and airway open maybe a little better????
That is of course assuming what we are seeing is obstructive primarily. Cheap easy experiment.

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Re: Forced to sleep on back now ASV ineffective

Post by ajack » Fri Apr 06, 2018 8:18 am

pugsy beat me to it, get a collar to keep the airway straight and I'll be very surprised if it doesn't fix it. You will probably need a flat pillow too.
once the main stuff is sorted, then adjust epap for what's left. your current 10 may work, I doubt you will need 12
put max epap and max PS on the max available. The machine will use what it needs

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Re: Forced to sleep on back now ASV ineffective

Post by SeekSleep » Fri Apr 06, 2018 6:09 pm

Last night I tried bumping Epap minimum up to 14, PS min 4 max 11 which is high as I could set that. Unfortunately I forgot to put my memory card back in so I have no sleepyhead data. I woke up at approximately 1:00 am with stomach full of air, took lots of belching to resolve. AHI was showing 37 point something. I turned EPAP min back to 10 and went back to sleep, Morning AHI on machine showed 16 so the rest of the night must have been pretty uneventful.

Today I purchased a cervical collar and I'll try that tonight. I'm going to leave the Machine is ASV auto and take the min EPAP down to 10 and see what happens. Thanks for the help folks. It doesn't appear my machine can correct my apnea on it's own right now so I'll have to find something like the collar, or a way to get comfortable on my side again to get back to sleeping good at night. I even went so far as going to the mattress store and trying new mattresses to see if their was anything that would let me lay on my side without the pain/discomfort I'm currently getting. On the air number bed I seemed to be able to find a setup where I aligned in such a way that I didn't hurt, but it wasn't really comfortable overall either and would probably make my back sore if I slept all night that way. Having them show me the price of the thing after I tried it I think the pain to the pocket book would interfere with sleep more than the pain from the surgery on our current bed.

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