Post
by Snoredog » Wed Aug 06, 2008 1:05 pm
Several things I see going on here, some are troubling. Those "NR's" showing up on your reports. If you look back at the pressure where they start kicking in your pressure is MUCH lower.
Going higher only drives your AHI UP, notice those "clusters" of OA? See where they correspond with NR?
Understand that when NR shows up the condition is pretty severe, for NR to show up it requires 3 sets of double events like apnea. Pressure will increase 3 cm's stair stepping up then "hold" machine says oops I screwed up and it immediately drops pressure by 2 cm and holds again locking out that circuit for a period of time.
Look at the 8/5-8/6 pressure report, notice after therapy hour 1 this starts, notice the "NR" tic? Notice it again an hour later,then again right before hour 3 and then again before 5 and rest of the session.
Having a single NR show up on your report is NOT good. Your reports show:
-stubborn apnea like a lodged tongue that couldn't be pried out with a crow bar OR
-a lot of central apnea caused by over titration.
-you have some snoring being logged, that says "obstruction"
-you have to ignore the HI's for the time being, those could be central
So which is it? A stubborn blockage like a cork stuck in a bottle (tongue in the back of the throat) or your body shutting down because it doesn't like the pressure delivery method (like a central)?
From your ID name, I assume you are a large man? What is your neck size? You have a large tongue? Have an overbite or receding chin? Have you always had difficulty with CPAP therapy? Are you sleeping on your back in the supine position or on your side?
Did this just show up when switching to the Swift mask? Personally, if it is what I suspect I don't think that interface will work for you, it cannot deliver the volume of air you need, reason for all the leaks, your nares may not be suited well for that type of interface and that could be another reason for all the leaks. If your nares are "slotted" that interface isn't going to work.
IF you do have a large tongue, you need to stick with a conventional nasal mask that goes over the nose, something like a ComfortGel (newer model), UltraMirageII or a Soyala. If it is a stubborn tongue we are trying to dislodge, the nasal mask interface is your best bet, that and sleeping on your side if you can. Much easier to move that tongue out of the way if you are on your side.
What if those events are central? Well they can very well be central based upon the frequency seen, those purple clusters stick out like a sore thumb on your report. IF they are central, you have to switch the machine from Auto to Bipap mode and manually titrate yourself (easily done when you know what you are doing).
What was your pressure when you were on CPAP?
That is the pressure you should start your Bipap EPAP at even in Auto mode. I would set PS=4. Only PS that appears to be getting used now is the built-in Minimum Pressure Support by the machine which is 2 cm. At therapy hour 6.25 where you apparently had a break there is some separation of IPAP/EPAP what looks to be 3 cm?? Do you have PS at default of 3? If so, you need to increase that to 4 or 5, I wouldn't go over 6 at this point.
So I would makes some changes and could use your feedback:
1. Change mask interface, if you have a conventional nasal I'd use it, last resort the UMFF.
2. Machine settings:
Therapy Type=Biflex Auto
IPAP Max=25 (current setting)
EPAP Min=12
PS=4
Try and practice even during the day to breathe through your nose, make sure you remove any nose hairs with one of those Panasonic nose hair trimmers they can make a big difference. Get some Saline nasal spray like SimplySaline, comes in an aerosol can has no preservatives. If you see a Neilmed Nasal rinse kit get one of those too.
Keeping nasal congestion under control (don't use ANY nasal sprays other than a saline solution, no Afrin, Sinex etc.). Use the conventional nasal mask if you can, do what you can on the leaks but don't tighten the straps to the point where it crushes the cushion or skirt on the mask, do that and well you have more leaks.
Leaks are only a problem on that machine when they get at or above 75L/m. When they reach that point report will show a solid black bar at the top. Your leak is climbing but so is your pressure, when pressure gets higher leaks are to be expected, I wouldn't loose any sleep over them. You do what you can and that is all you can do.
Try and sleep with your tongue planted into your hard palate, this will maintain the base of tongue to soft palate relationship and encourage nasal breathing. It is when that tongue relaxes back in the throat from that position do we have problems. With practice daily you can train yourself to not mouth breathe.
A lot of the mouth breathing taken place can be due to the stubborn OA, I mean if you are not getting air in the airway you are going to open your mouth to breathe, that is a given.
Have you been to an ENT for an exam? What did they say about your anatomy of the throat? Do you have an enlarged tongue and restricted airway? Probably losing some weight would help but you have to work with what you have now, so I would start with the mask and new machine settings shown above.
Note: Even with that machine in Auto mode, once you get over 12 cm pressure you almost have to manually titrate yourself with EPAP pressure. That means in order to address residual apnea, you need to manually move EPAP up to address it, IPAP you pretty much let it do its own thing and adjust PS. Right now OA is the problem and EPAP pressure is "pushing" up IPAP based upon machine's hard coded 2 cm "minimum" PS setting, so increasing PS Max is probably not going to have an effect, I would still set it to 4 or 5.
someday science will catch up to what I'm saying...
