- What can you do when CPAP doesn't work?
For Susie and her husband, Fred,
one change made all the difference.
This is their story. Let's take a look.
(upbeat music)
Good day, mates.
Susie is a member on our Facebook group.
If you'd like to join that group, click the link above.
And this is her post.
Anyone using an ASV machine and doing well?
My husband has complex apnea, is on lower dose oxys,
has had major nasal brain surgery
to take out an aggressive cancerous tumor and radiation.
He's okay now. Thank God.
He graduated from CPAP to BiPap four to five months ago
and still isn't doing well.
His apnea-hypopnea index is usually in the 20s to 30s,
and the last two weeks in the 50s.
And then last night with eight hours' use,
a new mask and new prescribed pressure, in the 60s.
Yesterday I cried so hard for him.
He's been through so much and I hope he doesn't quit.
I surely hope he gets an ASV.
Wow, what a story.
Susie and Fred,
sounds like you guys have been through a lot.
Well, let's head over to SleepHQ and check out your data
and see exactly what's going on.
So here we are on the dashboard sleephq.com.
And for those that don't know,
this is my CPAP data analysis platform
that I've built with my best mate, Adam, and it's free.
So if you'd like to use it to analyze your CPAP therapy,
just click the link above.
Crikey, check out this crazy high apnea-hypopnea index.
77.53.
That is enormous. (mimics explosion)
And that's with therapy.
Can you imagine what it must be without therapy?
It must be well over 100. That's insane.
Let's dive a bit deeper and see exactly what's going on.
Why is this number so high?
The goal is to try and get it less than five.
We're a long way off that.
Okay, so currently, the device is an AirCurve 10 VAuto.
So this is a ResMed BiPap machine.
First, let's take a look at the AHI donut.
This will give us a good idea
as to what classifications of apnea are contributing
to that high AHI number.
Here it is here.
So we have unclassified apnea, 9.19.
This means the machine couldn't determine
what type of apnea it was.
Then we have obstructive apnea, 5.32.
That's only a small amount.
And then we have this great big green bar. What's this?
Clear airway, 49.35.
So we can see right here on the donut,
the big problem here is the clear airway events.
These are central apnea events.
And we'll have a look at this in more detail now.
Let's scroll down to the flow rate.
And this is by far my favorite part of SleepHQ.
Having the ability to see every breath a patient takes
through the night is just incredible,
and you just don't get this information
on your myAir or your DreamMapper app,
which are quite basic.
Now I can zoom in on the flow rate
by clicking and dragging my mouse, like so.
Or I can also click Z as a hot key on my keyboard.
So you can see here at the start Fred breathing in and out.
In and out.
And you can see with each breath,
the amplitude gets smaller.
His breathing's starting to get shallow.
See here, they're getting smaller and smaller and smaller.
And then the breathing just stops.
It flat lines for about 20 seconds.
There's no longer any airflow
getting into or out of his lungs.
And then he starts breathing again, thank goodness.
But then the cycle repeats itself.
Look, it happens again here and here.
And if we zoom out,
you will see this pattern just repeating nonstop
hundreds of times through the night.
Have a look how many events there are.
Let's quickly zoom back in again
because there's one more thing I wanna show you here.
Now, just above the flow rate, the breathing,
is the therapy pressure levels.
You can see this green line here.
And what you can see is that it's very stable.
Even though this device is an automatic BiPap machine
that will vary the pressure automatically,
you can see right here,
it's behaving more like a CPAP machine
at one fixed level of pressure.
And you might be asking yourself, why is it doing that?
Because we've got all these events.
Shouldn't the machine be responding to the apnea,
increasing the pressure?
Well, no.
And I'll tell you why.
All these events here, CA, CA, CA, CA
are clear airway events, meaning the airway is open.
It's not blocked, like with obstructive sleep apnea.
So increasing the pressure isn't gonna change anything,
because we're not forcing air past any obstruction.
Airway's open.
Now there's lots of different manifestations
of central apnea, but they're all characterized
by a lack of drive to breathe during sleep.
And this results in repetitive...
All these repetitive periods of insufficient ventilation
and compromised gas exchange.
So lots of different forms of central sleep apnea,
but they all result in this same thing.
Fred has a type of central apnea
called cheyne-stokes respiration.
And it's characterized by this very specific pattern
that we're looking at right now,
where you have this waxing and waning of the breathing.
You can see here sort of shallow breaths in the start.
They get larger in amplitude,
then they get smaller in amplitude.
Then you have the central apnea
and the pattern repeats itself.
You can see it right here this wavy type pattern
called cheyne-stokes respiration, CSR.
Let's scroll forward through the night
just by clicking the right arrow on the keyboard.
There's one more thing I'd like to show you.
There's lots to talk about in this video.
And right here, something stands out, doesn't it?
So we have all these green clear airway flags.
And then all of a sudden, out of nowhere, we have this OA.
Obstructive apnea flag, this yellow one right here.
But it looks the same as the other ones.
And that's because it is.
This here is what we call...
Excuse me. (clears throat)
I've got a frog in my throat. A false flag.
It's not an obstructive apnea, it's a clear airway event.
And let's have a look what happened with the pressure.
So you can see here with the clear airway events
the pressure is remaining very stable.
It's not moving much.
And then all of a sudden it jumps from 14.48
up to 15.34 in response to this apnea event.
Because as we know, with obstructive apneas,
how do we treat them?
We increase the pressure.
But it was a false flag.
It shouldn't have been increasing the pressure.
It's really a clear airway event.
And the point I'm trying to make here in a roundabout way
is that whenever you have this complex apnea,
cheyne-stokes respiration, central apneas,
mixed apneas, unclassified apneas, complex apnea,
the machine algorithms are hopeless,
absolutely hopeless at auto-titrating the pressure.
So it's crystal clear,
Fred's current device, the AirCurve 10 VAuto is not suitable
for his cheyne-stokes respiration,
a form of central sleep apnea.
But let's see if anything changes
when he switches from the AirCurve 10 VAuto
to the AirCurve 10 ASV, adaptive servo-ventilator.
Here we go.
Holy shit balls.
AHI, 1.06, down from 77 on the VAuto.
Congratulations, guys, that is amazing.
And check out the daily usage, 10 hours and 16 minutes.
That's a damn good sleep.
Let's scroll down and check out the flow rate. Here we go.
All right, let's check out some of this breathing.
Ah.
It's a thing of beauty. Check that out.
Have a look at this breathing, nice and stable.
Every breath, the same amplitude.
What a difference this mode has made to Fred's therapy.
Congratulations, guys, that is just awesome.
And also congratulations to ResMed.
Those of you with the keen eye
might have spotted something on this page
that doesn't look quite right.
Can you see what it is?
You have this wonderful, stable, regular breathing,
but then up here on the pressure trace
it's all over the place.
It's up, it's down, it's everywhere.
Now normally, if you have nice stable breathing
the pressure trace is also nice and stable,
because there's no need to change the pressure
if your breathing looks good, right?
So what's going on?
Well, would you like to know how ASV works?
Of course you would. I'm gonna show you.
Okay, so let me break it down for you.
Now, ASV is some complex stuff,
but just bear with me and I'll try my best.
So this top trace here is the flow rate.
Breathing in, breathing out, breathing in, breathing out.
And you might recall this distinctive pattern.
This is the cheyne-stokes respiration
that we just looked at.
This periodic breathing
where you have these breathing pauses
between this waxing and waning pattern, okay?
Now ASV can pick up on these patterns.
And it uses what's called minute ventilation to do so.
Now, minute ventilation, without getting too specific,
is basically the volume of air
going into and out of your lungs per minute.
This dashed line here
is the targeted minute ventilation of the device.
The device has a target, a set volume of airflow
it's trying to achieve for the patient per minute.
And the solid line is the patient's minute ventilation.
So the machine has a target, and this is the information
that the patient is giving the machine, this wavy line.
Now, normally, someone who has stable, regular breathing
will have a nice flat minute ventilation
because there's the same amount of air
going into and out of the lungs per minute.
But for someone with cheyne-stokes respiration
we have this wavy pattern.
And that's because when the patient's breathing,
like they are here, the patient's breathing, all right?
There's gonna be more volume of air.
So the trace comes up.
And then when the breathing stops or gets very narrow,
the volume of air decreases
and so the minute ventilation drops.
And then all of a sudden (breathes heavily),
they're hyperventilating.
And so the minute ventilation increases again.
So you end up with this wavy pattern
and this is something the machine can pick up on.
And when it picks up on that, this is when it makes changes,
customized changes to the therapy pressure levels
to try and break that pattern from happening
and even out the breathing, as it's doing here.
So we'll go down here to the therapy pressure.
And the way it does this
is with something called pressure support.
And pressure support is the difference
between IPAP, inhalation pressure,
and EPAP, exhalation pressure.
So if we have an IPAP of 10 and an EPAP of six,
the difference is four.
And that's the pressure support level,
a pressure support level of four.
If we increase that pressure support level,
it really helps in ventilation,
removing the carbon dioxide from the lungs.
EPAP itself really helps in oxygenation,
bringing oxygen into the lungs.
And pressure support, the difference between IPAP and EPAP,
really helps in ventilation, removing the carbon dioxide.
But it can use this pressure support,
as you can see down here, to break that cycle.
So you can see here, the pressure support starts to increase
in response to this wavy minute ventilation pattern.
And then once again, it increases even further.
So the difference between the IPAP and EPAP is increasing.
And look what it does to the minute ventilation line.
It levels it out
so that it reaches the target minute ventilation.
I know that's a lot to take in, I do.
It's complex for me as well, but that's the best I can do.
I really hope you enjoy the video guys.
A big thanks to Susie and Fred
for letting me share their story today.
What an incredible turnaround, guys, congratulations.
To show my appreciation, I'm sending you a RemSleep O2 Ring
which you can use to monitor your blood oxygen level
and your heart rate.
Let's check what mine is.
94, 61 beats per minute. Looking good.
Now this ring is also gonna be integrated with SleepHQ.
So all that data from this ring will be integrated
with your CPAP therapy data, which will be awesome.
The take home message from today's video is this:
central sleep apnea is very common.
Around five to 10% of all people who have apnea
have some form of central apnea.
And if you are someone who's really struggling
to get your AHI number under control
and you look at your SleepHQ data
and there's a lot of clear airway events,
perhaps consider speaking with your specialist
to see if ASV is suitable for you.
Hope you enjoy today's video, guys.
If you did, give it the thumbs up, subscribe to the channel.
And as always, look after your mates, sleep well
and I'll see you soon, bye.
(upbeat music)