New to this- Husband vpap III 5 days but not taking breaths

[dsm]

FS it was indeed....
O.

Hmmm

Chasing FS away was not one of SAG's greatest achievements even if she had some unusual perceptions of her condition

DSM

[-SWS]

http://s281.photobucket.com/albums/kk21 ... titration/

Casiesia, just had a chance to take a peek. Pages 1 - 5 seem to be in order, but page 6 is a duplicate (of page 2). Is there a page 6 you can post at your convenience?

Thanks for posting these.

[Casiesea]

SWS - its a good thing you are double checking me!

Page 6 or 6 is the order form for the titration. No useful info. Sorry for the mix up.

[-SWS]

SWS - its a good thing you are double checking me!

Page 6 or 6 is the order form for the titration. No useful info. Sorry for the mix up.

Not a problem.

Looking at that PSG we can see a presumable complex SDB "balancing act" occurring in your husband's physiology. Your husband has two components to his sleep disordered breathing (assuming his current diagnosis is correct): 1) an obstructive component (that resolves with more and more pressure), and 2) a complex or machine-induced central component (that can progressively worsen with more and more pressure). These two SDB components comprise your husband's complex sleep apnea. And solving them using pressure alone can be quite a balancing act.

Quite often problem one above (normal obstructive sleep apnea) manifests most problematic during REM sleep. And quite often problem two above (machine-induced dysregulation) manifests most problematic during NREM (non-REM). Another common contrast between problems one and two is how sleep position can sometimes aggravate either. Supine sleep can aggravate ordinary obstructive sleep apnea (problem one). Conversely, side sleeping can sometimes aggravate complex or machine-induced central dysregulation (problem two). Hubby may need to experiment with sleep positions to discover the least problematic sleeping position (and if a recliner works best...). And, again, since the pressure requirements for these two SDB components can be diametrically opposed, finding an optimum pressure balancing act can be quite a challenge---even with SV type machines.

Ultimately, some complex sleep apnea patients rely on additional CO2 rebreathing (via added dead space) to augment adaptive servo ventilation type machines or even traditional PAP machines.

Losing weight just may be more important for your husband than for the rest of us, Casiesea. If he loses weight he just may get very lucky and require significantly less pressure to resolve his obstructive component. And guess what less pressure means for his complex component? Less required pressure is almost always a good thing for the complex central component as well! That means if your husband loses weight, then he just may get a much needed break and deal both obstructive and complex components an appreciable drop in severity. No guarantees about that, though. However, with a heart murmur your husband has triple incentive to lose weight. Add a wife and toddler to the equation and hubby has five times more incentive to lose that extra weight than most people. In my opinion he'll always need to keep close tabs on that heart murmur, since he is a complex sleep apnea patient. A potential chicken-or-egg question regarding your husband's complex problem in physiology presents itself here as well IMO.

You know by now, Casiesea, that my take is strictly non-expert and absolutely non-professional. But we like to type a lot on this message board. And I guess I'm no exception...


P.S. Does hubby have high nasal impedance? Swollen turbinates? Deviated septum? Fixing that can lessen his pressure requirements as well. And anything hubby can do to lessen his pressure requirements may significantly help both SDB problems one and two (his obstructive component and his machine-induced central component).

[RonS]

P.S. Does hubby have high nasal impedance? Swollen turbinates? Deviated septum? Fixing that can lessen his pressure requirements as well. And anything hubby can do to lessen his pressure requirements may significantly help both SDB problems one and two (his obstructive component and his machine-induced central component).

What about a full face mask?

Might that stop the leakage and perhaps even reduce the pressure required?

Just wondering.

[-SWS]

P.S. Does hubby have high nasal impedance? Swollen turbinates? Deviated septum? Fixing that can lessen his pressure requirements as well. And anything hubby can do to lessen his pressure requirements may significantly help both SDB problems one and two (his obstructive component and his machine-induced central component).

What about a full face mask?

Might that stop the leakage and perhaps even reduce the pressure required?

Well, I think full-face masks can certainly help with mouth leaks. However, I also suspect that many of us breathe through our mouths because we have problems with excessive nasal impedance. And as it turns out, breathing through the mouth does not necessarily decrease impedance compared to breathing through unimpeded nasal passages (bold emphasis below mine):

Another cause of OSA is nasal obstruction. The nose, best viewed as a variable resistor, contributes to nearly 40% of total airway resistance.[23] This resistance is greatly influenced by the vasomotor reaction of the nose to several factors, such as hormonal effects, metabolic changes, and numerous pharmacologic agents.[23] Olsen et al[24] measured the respiratory effort in a patient during sleep and suggested that the oral airway resistance was greater than the nasal airway resistance. With the nasal pathway being the preferred route for nocturnal breathing, an increase in nasal resistance will invariably increase the possibility of collapse of the nonrigid portion of the upper airway, namely, the pharynx.

That may sound counterintuitive at first, but the oral airway is truly impeded by a long and fairly obtrusive tongue.

The other important point mentioned above about high nasal impedance, is that it can actually contribute to an obstructive apnea occurring down in the pharynx. Partially pinch your nasal passages closed as you very deeply inhale, and you can feel those suction-type forces that contribute to airway collapse down in the pharynx. Eliminating excessive nasal impedance can conceivably lessen required stenting pressure---which can presumably be important to some complex sleep apnea patients regarding avoidance of counterproductive CPAP pressure thresholds.

Lastly some extremely wild speculation from me about any complex sleep apnea patient using a full-face mask to cope with high nasal impedance: I personally suspect incessant impedance-switching throughout the night (from nasal breathing to oral breathing), may be disruptive to an inherently "twitchy" complex-breathing-disordered etiology. I have absolutely no proof whatsoever to back up that suspicion. But I personally suspect stability regarding potentially "twitchy" stretch-receptor input may very well be key for some of these complex SDB patients. Or phrasing it another way: avoidance of even subtle pattern-destabilizing stretch receptor input may be neurologically crucial in some of these cases.
.

[dsm]

Jeeeze SWS

Here you come with a negative theory about nose to mouth breathing just when I am trying to prove the opposite here (see comments about switching from nose to mouth to both to whatever works )

DSM

viewtopic.php?t=30283&start=45

(How I practiced for 2.5 years just to be able to switch from nose to mouth at will )

Steve, its the good 'results' that win against any theories to the contrary

[-SWS]

Jeeeze SWS

Here you come with a negative theory about nose to mouth breathing just when I am trying to prove the opposite here (see comments about switching from nose to mouth to both to whatever works )

DSM

viewtopic.php?t=30283&start=45

(How I practiced for 2.5 years just to be able to switch from nose to mouth at will )

Steve, its the good 'results' that win against any theories to the contrary

Doug, while you may be shrouded in plenty of medical mystery, I don't think you happen to be an easily destabilized CompSA/CSDB patient. I agree that for the typical OSA patient, whatever it takes to get that adequate volume of air in is absolutely great!

And I also agree that same approach just may also be great for the CompSA/CSDB patient with high nasal impedance (a very good competing theory IMO). But I still suspect that an easily-destabilized CompSA/CSDB patient just may not fare as well as the rest of us regarding incessant impedance switching throughout the night. The big mystery is why CompSA/CSDB patients destabilize so easily with certain stimuli (such as machine pressure or perhaps even incessant impedance-switching) while the rest of us don't destabilize with any of those stimuli.

My suspicions still stand that avoidance of even subtle pattern-destabilizing stretch receptor input just may be neurologically crucial for some of these CompSA/CSDB patients (irrespective of Doug's great luck with highly prolific nose-to-mouth breathing changes).

But I think your thoughts and posts on that subject are absolutely superb for the rest of us who do not enigmatically destabilize so easily! And who knows... your observations may even be spot on for those CompSA/CSDB patients as well.

Good for us there are real scientists with real methodologies out there... hard at work! Because some of our syllogistic generalizations are merely that.
.

[Banned]

Does hubby have high nasal impedance? Swollen turbinates?
The other important point mentioned above about high nasal impedance, is that it can actually contribute to an obstructive apnea occurring down in the pharynx. Partially pinch your nasal passages closed as you very deeply inhale, and you can feel those suction-type forces that contribute to airway collapse down in the pharynx. Eliminating excessive nasal impedance can conceivably lessen required stenting pressure---which can presumably be important to some complex sleep apnea patients regarding avoidance of counterproductive CPAP pressure thresholds.

That's very enlightening. The reason I like the SV is because I prefer to breath through even an impeded upper airway. The SV applies the proper pressure to get through the ever changing swollen turbinates. Often times one nostril is totally blocked and there is still enough pressure being applied through the other mostly blocked nostril to allow me to comfortably go to sleep.

Does anyone know if Casiesea's husband is feeling any better at 10 + 3 = 13 then he did at 6 + 4 = 10?

Banned

[-SWS]

That's very enlightening. The reason I like the SV is because I prefer to breath through even an impeded upper airway.

I fall in that same category, Banned. If my nasal passages are impeded, I almost always continue to breath through those swollen nasal passages rather than naturally switch to mouth breathing. But there are still plenty of times when I do naturally switch to mouth breathing, warranting a full face mask (chin straps just didn't work for me).

APAP seems to have most often compensated adequately for my own variable nasal impedance. But then again my own central breathing doesn't seem to destabilize at any pressure between 4 and 20 cm. Trigeminal neuralgia is unfortunately keeping me from using any CPAP interface right now. Hope to be back on PAP after surgery in May.

So the theory for machine-destabilized CompSA/CSDB patients would be to keep the pressure requirements down by keeping the nasal impedance in check---but also by keeping BMI and any other pressure-relevant physiologic factors in check as well. The hope would be that keeping therapeutic pressure requirements down may help with that enigmatic destabilization in perhaps some CompSA/CSDB cases.

Does anyone know if Casiesea's husband is feeling any better at 10 + 3 = 13 then he did at 6 + 4 = 10?

Wondering about that as well. Hope he's getting some much needed rest.

[dsm]

There was a time when I really dislike mouth breathing - felt so wrong & uncomfortable - I would try to force my nasal system to operate. It was during that phase that I had trouble with the other Bipaps as mentioned in detail elsewhere. Last night I used a Bipap Auto (non SV) & got thru the night ok but woke several times to find the machine out of synch with me but I wasn't nose breathing but mouth breathing when this happened.

The lack of synch didn't really disturb me this time though as the Bipap Auto epap to ipap gap is so low it hardly makes a difference. But I can say I would not want the Bipap AutoSV to be as insensitive as the Bipap Auto was as I can picture the awful effect of being hit with 20 CMS out of synch. Plus with the Bipap AutoSV we can set real gaps & they need to be well synched.

Respironics must have made a big change in their switch sensing algorithm prior to the Bipap AutoSV & perhaps their use of the word revolutionary is a fair one.

Re the breathing for easily destabilised patients, I need to think that one through in light of how good my current results are when doing the nose mouth switch. This is a complex proposition.

DSM

[Lubman]

P.S. Does hubby have high nasal impedance? Swollen turbinates? Deviated septum? Fixing that can lessen his pressure requirements as well. And anything hubby can do to lessen his pressure requirements may significantly help both SDB problems one and two (his obstructive component and his machine-induced central component).

SWS has hit upon something that may apply to Casiesea's husband and
I think he also has pointed out an effect for me.

It's not necessarily nasal congestion or temporary blockage, but simply a
deviated septum or a narrow path in the nasal cavity that does seem to play a role. I am bigger and taller than Casiesea's husband (and I could also stand to lose 25 - 30 lbs, which would help any obstructive component),
but I was born premature by 3 months and my nasal passages were quite narrow for a person of my size.

About 7 or so years ago, i have some surgery to open them up, so to speak and i could noticeably breath better.

FS it was indeed....

Yes it was Freqseeker that urged me to try out of town specialists.
Christinequilts, as I recall, had several other conditions beyond sleep
apnea that complicated her situation. RG - have you seen her post elsewhere, as Christinequilts - who had done much of the studying toward
a PHd - really did a great job of taking note of machine differences and how they worked for her.

Another example of why, what treatment works for one, may not fit another.

Does anyone know if Casiesea's husband is feeling any better at 10 + 3 = 13 then he did at 6 + 4 = 10?

Higher pressure for CSBD is not always the answer. One of my sleep MD's
wondered if low pressure might be a better solution for my centrals - we
tried setting the ASV for the lowest min pS possible and the lowest EEP.
At that time I had not explored CO2 deadspace, and this low setting did not do much for me by itself. However, one of the things that attracted me to the ASV in the first place with the "gentleness" one experiences as it
follows ones breathing.

Lubman

[Casiesea]

Sorry, guys...sick kid. He does seem to feel better at 10/3. He seems to rest more soundly there, too.

Lubman- something you said got me thinking. He was also premature. His mom smoked when she was pg with him (chain smoked is my guess. If present behavior projects the past). He was raised with second hand smoke (both parents) and had many, many, many respiratory issues as a young child, we now have discovered. Tonsils/adenoids removed at 4 yrs old, weekly allergy shots, etc. One of his earliest memories is sleeping in a tent in the living room with a vaporizer on full blast.

Turbinates are swollen, he says he does feel like nasal impedance is an issue, I do not believe he has a deviated septum but I have been wrong before.

I have a kid screaming. Not sure I answered all the questions...I will be back.

[Lubman]

Interestingly enough, I just went to the Allergist, who said I had very narrow nasal valves, that tended to collapse when breathing in. Perhaps this is the change in Nasal Impedence that SWS mentioned that is contributing to apnea effects. Time to see a good ENT ...

None of this stuff happens independent of other effects.

Lubman

[-SWS]

Interestingly enough, I just went to the Allergist, who said I had very narrow nasal valves, that tended to collapse when breathing in. Perhaps this is the change in Nasal Impedence that SWS mentioned that is contributing to apnea effects. Time to see a good ENT ...

None of this stuff happens independent of other effects.

Lubman

Well, my own variable nasal impedance seems to be allergy-based. During allergy season I might experience several short-term episodes of rhinitis/swelling while sleeping (or trying to sleep). Usually Nasonex and APAP work exceptionally well for me.

My understanding is that there are quite a few physiologic ways that we might incur high nasal impedance. However, nasal valve collapse seems to be a fairly common problem:
http://www.emedicine.com/ent/byname/rhi ... enosis.htm

We also know that suction-type forces during inspiration can contribute to soft tissue collapse in those portions of the airway that are so inclined. However, to my knowledge there is absolutely no scientific evidence suggesting any improvement in CompSA/CSDB symptoms when nasal-impedance problems are properly addressed.

Please factor that reality in when electing for any surgical procedures to improve nasal impedance.

Truth be told, if I was a CompSA/CSDB patient with genuinely problematic nasal impedance, I would without question address those nasal impedance problems. However, I would be sure to solicit a second and third opinion before committing to any surgery that was not performed on a simple outpatient basis.

Good luck as always, Lubman!