Question for my partner's father (85 year old) 26 AHI treatment?

Hi

My gf's father is 85 years old and finally took a home sleep test and was diagnosed with moderate apnea, 26.3 AHI. (I had pushed for the last year to get him tested as he snores a lot, and energy is very low).

He tried an APAP (from Kaiser) for two weeks, with a full face mask (Resmed 10, with Resdmed F30) no humidifier, no heated hose (due to covid), and struggled with getting mask on/off each night. I coached him for several days and he was able to use it for 4 days out of the 10 days he had it. First 5 days he couldn't use it at all, and each day I worked with him to put mask on/off, and keep trying it, he slowly got better.

He didn't like it, and doesnt think he has a problem or that he needs it (he is in early stages of dementia, and had hip surgery last year, which seems to have affected his cognition).

He also has stenosis of the heart (ie one of his valves is affected).

My question is whether I should encourage him to try a cpap machine, hopefully the doctor will prescribe a BiPap (as that seems to be indicated for people with heart/pulmonary issues). If I don't, he will tell the sleep doctor he can't use the cpap and doesn't want to use it. If I encourage him to try a machine for a month or two he may agree.

The bad part is as his dementia progresses/he gets older and muscle coordination worses, he will find it tougher to use the cpap at some point.

Hopefully other option is Mandibular device (not sure Kaiser offers that but think they do so). Which will be easier to use, but tougher to monitor his usage or his treatment.

I know this is a complex case, however though would ask the folks for their thoughts.

Thanks

S

Tough one for sure.

I wonder if maybe he could manage a nasal mask better???
While not ideal maybe if he is much of a mouth breather.....some therapy is better than no therapy.

Take a look at the ResMed N30 nasal cushion (fits under the nose) mask. It's super easy to get on and sealed and certainly a lot more comfortable than most full face masks.
Even if it leaks sometimes with some mouth breathing....better than no mask at all.

With someone 85, mild cognitive impairment, and not really wanting to do this, it's going to be an uphill battle. It may be worth trying, but with the understanding that success is going to be a challenge and you may not have success. Kaiser Sr. Advantage coverage for CPAP is a perpetual rental, not capped, so if it's not working for him be sure he returns the machine.

I think in certain cases Kaiser MAY pay for an oral device with the right coverage See, for example: https://thrive.kaiserpermanente.org/car ... 888441.pdf Note the coverage requirements:

Patients who do not tolerate CPAP that are interested in an oral appliance should be aware:
- Insurance coverage for the oral appliance is available in those patients with appropriate DM E coverage for the
device with:
“Documented failure of CPAP therapy after appropriate attempts at CPAP initiation and/or maintenance.
Failure may be documented as 'patient intolerance' after attempting alternate interfaces and/or device
adjustment or re-titration as deemed necessary by the sleep lab physician.” (KP NCAL Coverage Guideline)
- This means that you must have tried and failed CPAP including multiple attempts at trouble shooting by our
department, which may include switching your mask , treating sinus congestion with nasal sprays , and
adjusting the settings on your machine in order for the appliance to be covered by your insurance plan.
- If you have not attempted CPAP, you will not meet the criteria for insurance coverage of the oral appliance.

An oral device will be difficult as well, and my dentist was quite frank with me that they don't really work for anything but very mild apnea. Even then they can cause a lot of jaw discomfort and TMJ issues and there are jaw exercises that should be done every morning to realign the jaw after wearing it all night. This may be very difficult for him to manage.

You are a good son-in-law to want to help him with this.

Thanks much and yes perhaps an N30 mask would make it easier for him, I do think he is a mouth breather, so if its a matter of no mask or a nasal mask, definitely a nasal mask is better. At Kaiser they gave him a F30 and a Resmed N20 and he decided to go with the F30 (the head gear is the same so putting it on and off is same difficulty and with some mouth breathing it was probably the right choice).

Yeah the tough part is knowing its a perpetual battle that likely won't be won.

One further q, should I push for a Bipap m/c as it will make exhalation easier and seems indicated for someone with heart issues and asthma. ?

Thanks so much for all your replies and the thought/care you put into helping others.

S

The AirSense 10 machines can be used as a limited bilevel machine by just making use of the EPR exhale pressure relief setting and it may be enough to be both comfortable and help with his overall breathing.
That's mainly what bilevel does anyway....allows for separate settings for inhale and exhale...that's all that bilevel really is anyway.
Insurance won't normally cover bilevel models of machines unless there is a specific known situation where it is needed.
Real bilevel machines offer greater than 3 cm difference between inhale and exhale and will go higher than 20 cm/
Unless he really needs much higher pressures to deal with the OSA or he is having extreme difficulty exhaling against whatever pressure he needs... ...he will need to prove a need for a different machine. Lots of people with various heart issues can do just fine on regular cpap/apap and don't really need bilevel.

EPR allows for up to 3 cm difference between inhale and exhale....it essentially functions like a bilevel machine does.
This is why we often call the machines offering exhale pressure relief like this the poor man's bilevel.

He needs to actually use the current machine for a period of time...maybe add in EPR...and get some sleep to see what pressures he needs as well as his response to this machine and then maybe if needed a bilevel machine discussion can be made. In most situations unless he has "failed" cpap...insurance won't spring for a bilevel machine.

You can use OSCAR and see what is going on in terms of pressures, events, leaks, etc.
Do you know about OSCAR?
OSCAR https://www.sleepfiles.com/OSCAR/
http://www.apneaboard.com/wiki/index.ph ... stallation
http://www.apneaboard.com/wiki/index.ph ... rpretation

His machine may or may not have come with a SD card in the machine. If it didn't any generic SD card will work...32 GB or less.

Do you have the provider manual?
https://www.respshop.com/manuals/ResMed ... %20her.pdf

Yup I have an Airsense 10 myself, and yeah know about EPR (I use EPR of 2) and that it helps a bit.

I don't know if he needs more than 20cm (unlikely) but more for the much lower exhalation pressure re BiPap as figure with stenosis there are some similar conditions to copd etc.

I am very familiar with oscar and posting charts, I do it for my therapy, and will do it for his too. First though need to encourage him to get a machine full time (the previous m/c was a 10 but a loaner) and a mask that is easy to get on/off and provides adequate therapy and then optimize therapy. I will be very happy if he is willing to try again and for a longer period of time. for the 4 days he used it, he had AHI number of 2.3, 7.5, 4.6 and don't remember last night. He complained of chest feeling heavy in the morning on the 4th night, and so I didn't push him to use it another night, and get his sleep and cardiologist doctor to check if the cpap could be causing any issues. Both said they don't cause any issues at least not heaviness in the chest.

Thanks

S

One further q, should I push for a Bipap m/c as it will make exhalation easier and seems indicated for someone with heart issues and asthma. ?

Kaiser is the health care provider (via sleep techs and pulmonologist), the insurer, and the DME. Crapria is merely the supplier, so if you are going to tackle this question is must be with the sleep techs or pulmonologist at Kaiser if your FIL will give you a HIPAA release to speak to them. All that crapria will do with Kaiser is fill the prescription as written by Kaiser, and even the particular mask has to be on the prescription.

Be aware that too much pressure can overload the heart given his conditions, so he really needs to work with his team on pressure changes.

Update

He talked to his sleep doctor, I was present too, and they ordered him a bipap machine (not that it would treat him better but perhaps to see if its more comfortable) with p10 and n30 masks, and are limiting max pressure to 15 or 16, he was using that much at the max, and complained that his chest felt heavy (maybe aerophagia), and they said if he experiences it again, take Gas X at night.

Kudos to Kaiser, prior to the call with the Dr, a nurse called him and told him (reinforced as he forgets) that treating apnea is important and he should get back to treatment.

Fingers crossed. (my sense is he can start at even lower pressures given nasal/pillows, and also to make it more comfortable) but will let Dr decide and let them know if there is discomfort to see what is possible.

Thanks all

Shriram

That is excellent news. Did they say what level of pressure support they will recommend? (You add PS to the exhale pressure to get the inhale pressure -- with EPR, you subtract the EPR from the inhale pressure. Go figure.)

The heavy chest may have been a little soreness in the chest muscles or the cartilage of the rib-cage, resulting from the extra effort of exhaling against pressure. With luck it'll pass soon and also be alleviated by some PS.

They didn't say what level of pressure support, however said that max pressure will be limited to 15 or 16, so not sure what exhale pressure it.

Hoping its more comfortable for him, and also that he isn't a huge mouth breather.

Thanks

S