Need help with Husband's Therapy.

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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Deborah K.
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Need help with Husband's Therapy.

Post by Deborah K. » Tue Sep 20, 2022 12:02 pm

I need help figuring out how to improve my husband's pap therapy. He has way worse apnea than I do, somewhere in the mid-90s. He has been using his bilevel machine a couple of years longer than me and has been happy with his therapy. But now that he has retired I notice that he falls asleep in front of the TV several times a day, so I think maybe his therapy can be improved.

As he uses a bilevel machine I don't know enough about what his setting ought to look like, so I am hoping you folks can help me choose the best settings for him. Another board advised me to raise his ps from 0.5 to 3.0. I did that yesterday and Alan says he slept better last night. But they did not answer my other questions. Here are some charts:
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As you can see he has some Periodic Breathing and LOTS of Variable Breathing. Are there settings that can improve these? He has lots of leaks too. He uses a chin strap, but it does not appear to be working very well. Hopefully, I can talk him into using a neck brace and/or taping his lips.

P.S. His machine is new, sent to us directly from Philips, so that is not an issue.

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Re: Need help with Husband's Therapy.

Post by robysue1 » Tue Sep 20, 2022 5:24 pm

Deborah K. wrote:
Tue Sep 20, 2022 12:02 pm
I need help figuring out how to improve my husband's pap therapy. He has way worse apnea than I do, somewhere in the mid-90s. He has been using his bilevel machine a couple of years longer than me and has been happy with his therapy. But now that he has retired I notice that he falls asleep in front of the TV several times a day, so I think maybe his therapy can be improved.
On paper, his OSA is well controlled on the nights that you posted data for. The AHI is well below 5.0, and there are no real clusters of events on either of the two nights.

So that raises the question: Is there something else that could be affecting his sleep??

As you've noted: There does seem to be some Periodic Breathing and LOTS of Variable Breathing.

My own (older) DreamStation Auto BiPAP does not record Variable Breathing. I've seen posts here that indicate Resmed machines don't try to flag "Variable Breathing" and I've seen posts that indicate that exactly what criteria PR uses to flag something as Variable Breathing is not exactly clear. So it's not clear whether dial winging will ever make the machine record less Variable Breathing.

Periodic Breathing, on the other hand, is something that my machine flags and that actually does have some stuff that is better understood around here. Periodic breathing is a characteristic waxing and waning pattern in the breath-by-breath data recorded in the Flow Rate graph, and when Periodic Breathing is particularly significant in terms of sleep apnea is when the periods are separated by a central apnea. It's one of the things that can pop up in the Flow Rate chart for people who are dealing with Central Sleep Apnea instead of ordinary OSA. The problem in CSA is that the brain forgets to send a message to the diaphragm to "inhale now" because the brain is somehow not seeing the CO2 trigger needed to send the signal to the lungs and diaphragm to inhale. There are some people who suspect that when the PS (pressure support) setting gets too high that can cause a person to "blow off" too much CO2, leading to the characteristic periodic breathing pattern and (sometimes) problems with central apneas being scored by the machine. But when CSA is an issue, we typically see a CAI that is over 5, and usually well over 5. (Your husband's maximum CAI = 0.28 on 9/12, which is statistically insignificant.)

But that really doesn't seem to be the problem here: There are hardly any CSA's being scored and the total time in Periodic Breathing is not very much. Moreover, your husband seems to have more problems with Periodic Breathing when the PS is very low (i.e PS = 0.5 to PS = 2.5) than when the PS was set to 3.

You also write:
As he uses a bilevel machine I don't know enough about what his setting ought to look like, so I am hoping you folks can help me choose the best settings for him. Another board advised me to raise his ps from 0.5 to 3.0. I did that yesterday and Alan says he slept better last night. But they did not answer my other questions.
It looks to me like you did more than just change the PS setting. On both 9/12 and 9/17, the machine is clearly in Auto mode because there are pressure adjustments. But on 9/19 there are no pressure adjustments at all through the whole night, which is highly unusual for a machine in Auto mode, even though OSCAR is still saying the machine is in automode.

As for why your husband said he slept better after you raised the PS fro 0.5 to 3.0: Essentially PS is a form of "exhale relief"---it represents how much the pressure is allowed to go down when your husband starts to exhale. And for many people, a PS of 3 is simply makes it much easier to exhale against the pressure and that in turn can mean fewer problems getting to sleep and staying asleep during the night.

You also write:
As you can see he has some Periodic Breathing and LOTS of Variable Breathing. Are there settings that can improve these? He has lots of leaks too. He uses a chin strap, but it does not appear to be working very well. Hopefully, I can talk him into using a neck brace and/or taping his lips.
His leak lines actually look OK. Not great, but OK. The excess leaks (bottom leak line) never get into "Large Leak" territory, so his therapy is not being compromised by the leaking. If his leaks are waking him (or you) up, then they need to be fixed for that reason. But unless the leaks are actually waking him up (instead of you), fixing his leaks is not likely to improve his sleep very much, but it will improve yours if they're waking you up.

I would not push him into taping his lips: Lots of people find taping their lips is highly uncomfortable and for some people it can trigger genuine, but perhaps a bit irrational, worries about what happens if they need to spit/throw up in the middle of the night.

Likewise, using a neck brace may increase his discomfort while trying to get to sleep at the beginning of the night---they can be pretty hot to wear on a muggy night. So again, if he doesn't want to do that, I would not push him to do that.

You might, however, encourage him to fit the mask after he is lying down in his usual sleep position and with the machine running.

Finally I will add these things:

1) It would help us help you if we know why your husband was prescribed a BiPAP in the first place. They are typically prescribed for specific reasons. In my case, I simply could not adjust to CPAP/APAP even with exhale relief maxed out because of severe aerophagia problems. And the switch to BiPAP was a godsend to my stomach and the aerophagia problems. But I'm pretty unusual in that sense and most people are prescribed BiPAPs for lots of other reasons.

2) If it's been a while since your husband has had a full check up with his PCP it's probably time to schedule one: Sometimes periodic breathing can be associated with certain forms of heart disease. And in that case, you need to treat the heart disease rather than dial-winging the BiPAP.

3) If your husband is known to not have any heart disease, I'd leave the new PS setting in place for at least a week or so to see if your husband continues to report that he's feeling better when he wakes up.

4) There are other causes for daytime sleepiness than OSA. And your husband's OSA is currently controlled. So it's reasonable to start asking, "What else might be causing sleep problems and/or daytime sleepiness/fatigue?" And again, that starts with a physical exam by his PCP and a chat about what kinds of things he has (medical conditions, medication, life-stress issues, etc.) that might be causing the daytime sleepiness.

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Deborah K.
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Re: Need help with Husband's Therapy.

Post by Deborah K. » Tue Sep 20, 2022 5:49 pm

Thanks for responding! All I changed was the ps jump to 3.0, nothing else. Would it be good to raise it a little more?

He was prescribed a bilevel because his home study made the doc think he probably needed it, so he went to a hospital to have a titration study done. Only then did his doc order the pap machine.

He sees his docs pretty regularly, and we don't know of anything else that would affect his pap therapy. I might search his few prescriptions to see if any of them have side effects that could interfere with pap therapy.

Again, Thanks for your help!

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Re: Need help with Husband's Therapy.

Post by robysue1 » Tue Sep 20, 2022 6:35 pm

Deborah K. wrote:
Tue Sep 20, 2022 5:49 pm
Thanks for responding! All I changed was the ps jump to 3.0, nothing else. Would it be good to raise it a little more?
I would not raise it any more. I'd leave the settings alone for at least 3 or 4 days. Or even a week. And unless there's something other than a vague sense of trying to improve the numbers, I'd leave the PS where it is unless your husband says he's feeling worse.
He was prescribed a bilevel because his home study made the doc think he probably needed it, so he went to a hospital to have a titration study done. Only then did his doc order the pap machine.
But why did he get a biPaP instead of just a cpap or an apap? It's very unusual for a person's first machine to be a bi-level machine. Did you ever get copies of the sleep study results, including the full summary and the summary graphs?
He sees his docs pretty regularly, and we don't know of anything else that would affect his pap therapy. I might search his few prescriptions to see if any of them have side effects that could interfere with pap therapy.
His pap therapy is working: His AHI is where it is supposed to be. The question that needs to be looked at is whether there is something else that could be affecting his sleep and/or causing the daytime sleepiness. Because right now, it doesn't look like his daytime sleepiness is the result of less than optimal PAP therapy.

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Re: Need help with Husband's Therapy.

Post by Deborah K. » Tue Sep 20, 2022 11:21 pm

We have decided not to worry about it unless someone comes along with a new idea, which seems unlikely. His small improvement is enough for now. :)

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Re: Need help with Husband's Therapy.

Post by Respirator99 » Wed Sep 21, 2022 2:19 am

robysue1 wrote:
Tue Sep 20, 2022 6:35 pm
... But why did he get a biPaP instead of just a cpap or an apap? It's very unusual for a person's first machine to be a bi-level machine. Did you ever get copies of the sleep study results, including the full summary and the summary graphs? ...
His minimum EPAP is 17.0. I understand that in your country such a high EPAP automatically triggers consideration of a bilevel machine.
It looks to me like you did more than just change the PS setting. On both 9/12 and 9/17, the machine is clearly in Auto mode because there are pressure adjustments. But on 9/19 there are no pressure adjustments at all through the whole night, which is highly unusual for a machine in Auto mode, even though OSCAR is still saying the machine is in automode.
When PSmin was set at 0.5 the IPAP was 17.5, with occasional excursions up to (but not exceeding) 19.1. With PSmin set to 3.0, then IPAPmin became 20.0, which is higher than required. Hence, no pressure changes on that night. So it looks consistent with PS being the only change to settings.
Last edited by Respirator99 on Wed Sep 21, 2022 6:17 am, edited 1 time in total.
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Re: Need help with Husband's Therapy.

Post by robysue1 » Wed Sep 21, 2022 6:10 am

Respirator99,

Thank you for answering my questions!

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Re: Need help with Husband's Therapy.

Post by Rubicon » Wed Sep 21, 2022 6:44 am

I think you need a deep breath dive into doing something about the VB. Used to be (and probably still is) that a lot of machine operations are affected if the machine is in VB Layer (from a 2006 discussion):
Variable Breathing Pressure Control

Once the variable breathing controller has been granted control of the pressure support system, it takes some initial action based on the action the auto-CPAP controller is taking. After this initial action, it performs an independent pressure control operation.
A prior pressure that is flat will cause the pressure delivered to the patient to remain at that level.

A prior pressure that is increasing will cause the variable breathing controller to initially decrease the pressure delivered to the patient at a rate of 0.5 cmH2O per minute. The magnitude of the decrease is dependent on the magnitude of the increase in prior pressure. The pressure decrease is intended to erase the prior pressure increase that possibly caused the variable breathing. However, the total decrease in pressure drop is limited to 2 cmH2O. After pressure decrease, the variable breathing controller holds the pressure steady.

A prior pressure that is decreasing will cause the variable breathing controller to initially increase the pressure delivered to the patient at a rate of 0.5 cmH2O per minute. The magnitude of the increase is dependent on the magnitude of the decrease in prior pressure. The pressure increase is intended to erase the prior pressure decrease that may have caused the variable breathing. However, the total increase in pressure is limited to 2 cmH2O. After pressure increase, variable breathing controller holds the pressure steady.

The pressure curve is provided for 5 minutes or until the variable breathing condition clears. Thereafter, the pressure is controlled according to the following:

The pressure is either maintained at a constant value, or it follows a decrease and hold pattern. The decision to hold the pressure or to decrease the pressure is made by comparing the current pressure with the snore treatment pressure. It is to be understood, however, that this duration can be varied over a range of durations.

If there is no snore treatment pressure stored in the system, which will be the case if the snore controller has not been activated, the pressure is held constant. If there is a snore treatment pressure, and if the current pressure is more than a predetermined amount above this snore treatment pressure, such as more than 2 cmH2O above the snore treatment pressure, the variable breathing controller decreases the pressure to a level that is a predetermined amount higher than the snore treatment pressure and holds the pressure at the lower level. The pressure decreases to the snore treatment pressure +1 cmH2O.

The duration during which pressure is provided according to the paradigms discussed above for region is set to 15 minutes or until the variable breathing condition clears. It is to be understood, however, that this 15 minute duration can be varied over a range of durations.
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Re: Need help with Husband's Therapy.

Post by robysue1 » Wed Sep 21, 2022 7:08 am

^^^

So this tells us how the variable breathing controller affects the machine's decision about whether to leave the pressure alone, increase it, or decrease it, as well as what the rate of increase/decrease is.

But having read it, I still don't see information about what variable breathing is and how/why it gets flagged in the OSCAR data.

Care to enlighten me (and the rest of us) on what characteristics the machine is looking for to flag something as variable breathing and then (presumably) hand control over to the variable breathing controller?

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Re: Need help with Husband's Therapy.

Post by Rubicon » Wed Sep 21, 2022 7:24 am

http://www.apneaboard.com/wiki/index.ph ... responsive

Better yet, put the OP's waveforms under the magnifying glass and you'll see exactly what his VB looks like.
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Re: Need help with Husband's Therapy.

Post by Rubicon » Wed Sep 21, 2022 7:29 am

But IMO VB would be composed of SWJ and phasic REM (mostly SWJ).
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Re: Need help with Husband's Therapy.

Post by Deborah K. » Thu Sep 22, 2022 12:30 pm

So, is there a setting I can change to help with my husband's variable breathing?

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Re: Need help with Husband's Therapy.

Post by Rubicon » Fri Sep 23, 2022 2:19 am

Deborah K. wrote:
Thu Sep 22, 2022 12:30 pm
So, is there a setting I can change to help with my husband's variable breathing?
I think you have to figure out why it's there first.

Load up a typical night into https://sleephq.com/.
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Re: Need help with Husband's Therapy.

Post by Rubicon » Fri Sep 23, 2022 2:39 am

robysue1 wrote:
Tue Sep 20, 2022 6:35 pm
It's very unusual for a person's first machine to be a bi-level machine. Did you ever get copies of the sleep study results, including the full summary and the summary graphs?
This.

You got a pretty aggressive approach there, maybe too aggressive. Probably the cause of the PB.

You might want to include 9/17 in the upload since that's got a lot of PB, and the average IPAP is less than set EPAP. Might need to upload actual data file (to use Oscar) instead of SleepHQ to try to figure out why that is.
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Re: Need help with Husband's Therapy.

Post by Rubicon » Fri Sep 23, 2022 2:47 am

Image

So this makes no sense to me.

Must have been all those shrooms.

I knew I'd have to pay for that at some point.
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