Helping my 4 year old

[sleeplessmommy]

We are two months into CPAP use with my son and in the process of getting palatal expander fitted which I hope will be in place by the end of this month. He is on a PR System One with humidifier CPAP machine and uses the pixi or wisp with pad a cheek and a pressure setting of 5. He had tonsils and adenoids out in March which did nothing for his OSA.

We do see his pediatric sleep specialist in several weeks, but I was looking for practical suggestions tobsolve his biggest problem with CPAP. He has frequent night wakings and arousals, thrashes around in his sleep and the mask gets ripped off his face in his aroused, confused state. He gets combative (in his sleep) when I try to get it back on and won't sleep through me trying to get it back on when he is in a deeper sleep. The problem is not getting him to wear it to bed--he does this without a fight so incentive charts won't work. He is not getting more than 3-4 hours a night before the first arousal and the mask coming off. I hoping with the palatal expander, he can forego the CPAP machine in the future, but if there is anything anyone can think of that may help? Sort of confusing as I thought the CPAP would decrease the arousals and restlessness. His AHI hovers around 3-5 with the current settings.

[Lazer1234]

When it comes to children and cpap, I have little knowledge, but can tell you what happens to me. I have had the cpap for 2.5 years, and it's the last 6 months I got it to work. I have had a minimum pressure of 8.5 and a maximum of 13 and it has been good. Now I'm into a lot of different forums and try to help people with sleep disorders. I have experimented with different pressures, and I've noticed now that I have driven for 3 weeks with minimum pressure 4 and a maximum of 20 so have AHI been good but I have had bad sleep with many awakenings. Tired of day. Now that I changed back to 8.5 to 13 so I slept well through the night again. In this way, the pressure has affected my sleep.

[Julie]

I wonder if his pressure is high enough to do the job - sometimes doctors are so conservative about starting at 'the lowest number that will work' that the settings need to be adjusted (almost inevitably) later on so the patient can breathe easily, but with a 4 yr old you need to work with the doctor and ask about that rather than making changes yourself. Also, is there a chance the CO2 vent gets covered by bedding when your son turns in bed? That would cause a reaction too - it's so important to keep it clear.

[Sludge]

How much total sleep do you think he actually gets per night?

Is he presently on any medications?

What is his current AHI?

[BlackSpinner]

You will need to have a look at his data using software to see what is happening at the times he starts doing this.

Look at the top of the page for the thread of Pugsy's introduction to using sleepyhead software. Then post the graphs here for people to help you read them.

viewtopic/t88983/Pugsys-PointersSleepyH ... Hints.html

[Janknitz]

I'm sorry as this does not directly address your question, but when considering Palate expanders, be sure to ask about the Damon System for doing that http://www.bernsteinbraces.com/orthodon ... f-ligating (I am not affiliated in any way with this system, just very pleased about my daughter's results). Many orthodontists use the system with the expander in the center of the palate that must be adjusted with the use of a tool every day. It puts hardware on the roof of the mouth, so the tongue cannot rest flush against the roof of the mouth. This MAY cause issues with getting a good CPAP seal, and my child's orthodontist, who trained in South Africa where there is a lot of emphasis on skeletal growth and development in the orthodontia curriculum, feels that it's vitally important NOT to impede the tongue position since the tongue on the roof of the mouth helps to shape the palate in a more natural way.

The Damon system is applied to the outside surface of the teeth and expands the palate through activated wires that only have to be changed every 2 months or so. It was very well-tolerated by my daughter who has some sensory issues, it worked quickly and with very little discomfort. She had a very good response in only about 2/3 of the anticipated time it was expected to take.

As for your direct question, the data reading software suggested above is your best bet. I had a low AHI but I was waking at night with night sweats. When we saw my graph, I could see that my pressure was hanging out at the highest setting around that time. Raising the pressure just a little smoothed that out and I slept more peacefully.

[sleeplessmommy]

How much total sleep do you think he actually gets per night?

Is he presently on any medications?

What is his current AHI?

He gets between 8-9 hours of interrupted sleep a night. Not enough but the best he can do with a very good sleep hygiene routine in place. Sometimes I can get him to take a 1-2 hour nap if I drive him around after a bad night. He takes no meds.

AHI is usually 4-5ish down from ~15 events an hour on his last study. Will try to post the graphs later when I get home. He has a lot of parasomnias at night. Exhalation port seems clear but will pay more attention tonight.

[JDS74]

It sounds as if he might benefit from getting up with the first arousal and doing omething quieting for an hour or so. Then back to bed with mask, etc.

That's what I do when I get an arousal and can't get back to sleep in 20 minutes or so.
If that works, he may get two sessions of 3 hours of sleep instead of just one.

[sleeplessmommy]

Here are two screenshots, the first was two nights ago, when he woke up and ripped the mask while still asleep after several hours. The second screenshot, he went over 9 hours with the mask on:
Ripping mask off:


Full usage:


Any idea how I can get him sleep more soundly so he will keep the mask on all night?

[Janknitz]

Well, he's definitely having more centrals in REM sleep. Has his sleep doctor seen his graphs?

[mgaggie]

Well, he's definitely having more centrals in REM sleep. Has his sleep doctor seen his graphs?

How can you tell when he is in REM sleep?

[sleeplessmommy]

The doctor hasnt seen them yet. He goes for a 3 month follow up in a couple more weeks.

[Janknitz]

How can you tell when he is in REM sleep?

My understanding is that REM sleep occurs 2-3 hours in, which is what it looks like here.

[Sludge]

How much total sleep do you think he actually gets per night?

Is he presently on any medications?

What is his current AHI?

He gets between 8-9 hours of interrupted sleep a night. Not enough but the best he can do with a very good sleep hygiene routine in place. Sometimes I can get him to take a 1-2 hour nap if I drive him around after a bad night. He takes no meds.

AHI is usually 4-5ish down from ~15 events an hour on his last study. Will try to post the graphs later when I get home. He has a lot of parasomnias at night. Exhalation port seems clear but will pay more attention tonight.

A few thoughts:

• Pre-school children (3-5 years) need 11-13 hours of sleep, so that 8-9 hours of sleep (due mostly to that very late bedtime) is certainly insufficient.
• Parasomnias can be caused by insufficient sleep.
• The severity criteria for OSA in children is:
  • Normal <1.0 (some folks say <3.0)
  • Mild 1.0-5.0.
  • Moderate 5.0-10.0
  • Severe 10.0
• Consequently, those 11.0-15.0 AHIs previously referred to as moderate are actually severe (although one needs to look at obstructive events-- if a lot of those were central, one would temper that assessment).
• It may be beneficial to look at the the diagnostic and treatment NPSGs for clues, including to see if they were correctly scored.
• That said, since application of CPAP has stopped bedwetting, that's certainly an excellent sign that you're on the right track.
• That said2, one might wonder (if the machine scoring is correct) that the prescribed pressure is inadequate. Residual OSA of 2.0 is a lot.
• Following that, one must consider "Causes of Disturbed Sleep in Children"...

[Lazer1234]

I think he needs more pressure.