Sleep Apnea - Choking with CPAP onSeeking help and medication advise for my father whose details I have tried to put in below. Thanks in advance for all who could help as I have given up on any further allopathic investigations. Please also let me know if I need to provide additional information.
Nature of work: Retired
1. Describe your main suffering?
My father has been diagnosed with severe obstructive sleep apnea for the last 2 years and he is on a auto CPAP machine, his titration pressure advised was 7. He does not have a problem of snoring anymore and neither does he have a problem sleeping. The main problem I am seeking help is he has choking attacks at night even with the mask on, there are no leakages in the mask and I have tried a couple of machine and he currently uses the latest machine from respironics.
All tests related to cardiology are normal and I have shown him also to a Neuro surgeon who said there are no neurological problems.
In the latest blood test RDW was on a higher side at 19%.
Specific symptoms are we hear a choking sound and he starts gasping for breath for about 5 minutes and then the breathing returns to normal. There is also a snorting sound during such attacks.
He bites his tongue and bleeds slightly along with mucous. After the attack he is spaced out for about 15 minutes and returns to normal at the end of approximately 20 minutes. I have rushed him to the hospital several times after the attack and all vitals are normal.
He does not have any other jerks or bed wetting to even consider nocturnal seizure.
The frequency of the attacks have increased from once in six months to now once a week and sometimes twice in the night. He is very regular in wearing the mask and using the CPAP device.
I am not looking for improvement in sleep and do not want anything that would sedate him as I feel this will complicate, I am looking of ways to stop or reduce these attacks before they create a problem.
2. What other physical sufferings do you have in your body?
My father is a mild diabetic and is on diapride forte. He also complains of constipation many times.
3. What mental sufferings / feelings do you have associated with your physical sufferings?
My father was also diagnosed with Bi polar disorder and is on Arpizol 5 mg, we have tried with and without the tablet but he continues to have these attacks either way. He also is quite depressed these days after the attacks did not stop with the new machine.
4. What exactly do you feel when you are at your worst? Describe the sensation in your own words.
He feels generally tired and of late has sometime problem walking and loses balance.
5. When did it all start? Can you connect it to any past event or disease?
2 years before, it started with a choking attack and after several visits to Cardio, neuro and pulmonary this was diagnosed as obstructive sleep apnea after a polysomnagraphy.
6. Which time of the day you are worst?
The attacks are at night mostly 2 -3 hours after sleep or 2-3 hours before waking up. He has so far has only 1 attack during day when he was sleeping without the mask on.
7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc.
It seems mostly he gets them on days when he is more exhausted or mentally more disturbed though it is difficult to confirm this.
8. When do you feel better, during hot weather or cold weather, humid or dry weather?
Does not seem to be related to weather as the attacks have occurred in all seasons.
10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc.
My father has always been an angry man and is easily offended, about 4-5 years back he had sobered down a bit but he again went into mood swings an year back and diagnosed with Bi polar, after being on Arpizol he has sobered down and is actually a bit depressed.
11. What do you crave for in food items and what are your aversions?
Nothing in particular.
12. How is your thirst: Less, Normal or Excessive?
13. How is your hunger: Less, Normal or Excessive?
Was normal until about a month back but over the last 3 weeks has reduced ever since the new machine also did not work.
14. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs?
14. How is your bowel movement and stool type?
Not noraml, he is constipated many times.
15. How well do you sleep? Do you have a particular posture of sleeping?
There have never been problems with his sleep and after the sleep apnea diagnosed he sleeps on the side.
16. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication?
Only the CPAP machine
17. What major diseases are running in your family?
Nothing in particular other than my father being a mild diabetic.
Apneachoking on 2010-04-15
The non-surgical treatments for obstructive sleep apnea are similar to the non-surgical treatments for snoring with a few differences. Treatments include:
* behavioral changes,
* dental appliances,
* CPAP (continuous positive airway pressure), and
Behavioral changes are the simplest treatments for mild obstructive sleep apnea, but often the hardest to make. Occasionally, apneas occur only in some positions (most commonly lying flat on the back). A person can change his or her sleeping position, reduce apneas, and improve their sleep.
Obesity is a known contributing factor to obstructive sleep apnea. It is estimated that a 10% weight gain will worsen the apnea-hypopnea index by 30%, and a 10% weight loss will decrease the apnea-hypopnea index by 25%. Therefore, a healthy lifestyle and diet that encourages weight loss will improve obstructive sleep apnea.
Unfortunately, most people with obstructive sleep apnea are tired and do not have much energy for exercise. This is a difficult behavioral spiral since the more tired a person is -- the less they exercise -- the more weight they gain -- the worse the obstructive sleep apnea becomes -- and the more tired they become. Frequently, after obstructive sleep apnea is treated by other methods people are able to lose weight and the obstructive sleep apnea may improve.
Sleep hygiene and other behavioral modifications known to improve the overall quality of sleep are also recommended. Below are some common practices that can induce sleep and enhance its quality:
* reduce lighting and noise in the bedroom;
* avoid reading or watching TV in bed;
* avoid eating or exercising prior to sleep;
* use the bedroom only for sleeping;
* keep work related activities outside of the bedroom; and
* try a period of physical and mental relaxation before going to bed.
Many medications have been studied for obstructive sleep apnea; however, because obstructive sleep apnea is due to an anatomic airway narrowing it has been difficult to find a medication that helps.
* In people with nasal airway obstruction causing obstructive sleep apnea, nasal steroid sprays have been shown to be effective. In one study, the respiratory disturbance index (RDI) decreased from 20 to 11 with nasal sprays.
* Topical nasal decongestants such as oxymetazoline and neosynephrine, also can temporarily improve nasal swelling. The problem is that they cannot be used for more than 3-5 days without decreased effectiveness and withdrawal symptoms.
* People who have obstructive sleep apnea due to hypothyroidism (low thyroid hormone production) improve with thyroid replacement therapy. However, people with normal thyroid function, will not improve with this therapy.
* People who have obstructive sleep apnea due to obesity may improve with diet medications if they are effective in assisting with weight loss.
* Other medications have been studied, including medroxyprogesterone (Provera, Cycrin, Amen), acetazolamide (Diamox) , theophylline (Theo-Dur, Respbid, Slo-Bid, Theo-24, Theolair, Uniphyl, Slo-Phyllin), tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRIs). In these studies, they were shown to have little or no effect. There are also new medications to help increase alertness. They may be temporarily successful in increasing attention; however, they do not treat the sleep deprivation or the cause of obstructive sleep apnea.
* In cases where sleep apnea may be caused by another underlying condition, appropriate treatment of such conditions is recommended and may be beneficial. For example, treating underlying heart failure may improve sleep apnea if it is a contributing factor. In people with sinusitis and nasal congestion, the swelling and inflammation of the upper airway passages can cause snoring and sleep apnea. Therefore, medications to treat underlying sinusitis and congestion can potentially improve sleep apnea in these individuals.
A dental appliance holds the jaw and tongue forward and the palate up, thus preventing closure of the airway. This small increase in airway size often is enough to control the apneas.
Dental appliances are an excellent treatment for mild to moderate obstructive sleep apnea. It is reported to be about 75% effective for these groups. A dental appliance does not require surgery; it is small, portable, and does not require a machine. However, there are some disadvantages to the dental appliance. It can cause or worsen temporomandibular joint (TMJ) dysfunction. If the jaw is pulled too far forward, it can cause pain in the joint when eating. For this reason, it is best to have a dentist or oral surgeon fit and adjust the appliance. A dental appliance requires natural teeth to fit properly, it must be worn every night, and the cost is variable, as is insurance coverage.
Continuous positive airway pressure (CPAP)
Continuous positive airway pressure (CPAP) is probably the best, non-surgical treatment for any level of obstructive sleep apnea. In finding a treatment for obstructive sleep apnea, the primary goal is to hold the airway open so it does not collapse during sleep. The dental appliances and surgeries (described later) focus on moving the tissues of the airway. CPAP uses air pressure to hold the tissues open during sleep.
CPAP was first used in Australia by Dr. Colin Sullivan in 1981 for obstructive sleep apnea. It delivers the air through a nasal or face-mask under pressure. As a person breathes, the gentle pressure holds the nose, palate, and throat tissues open. It feels similar to holding your head outside the window of a moving car. You can feel the pressure, but you can also breathe easily.
The CPAP machine blows heated, humidified air through a short tube to a mask. The mask must be worn snugly to prevent the leakage of air. There are many different masks, including nasal pillows, nasal masks, and full-face masks. The CPAP machine is a little larger than a toaster. It is portable and can be taken on trips.
Determining CPAP pressure: With CPAP it is important to use the lowest possible pressure that will keep the airway open during sleep. This pressure is determined by 'titration.' Titration frequently is performed with the help of polysomnography. It can be performed during the same night as the initial polysomnography or on a separate night. In the sleep laboratory an adjustable CPAP machine is used. A mask is fit to the person and he or she is allowed to fall back asleep.
During baseline sleep the apneas and hypopneas occur, and the the technician then slowly increases the CPAP pressure until the apneas and hypopneas stop or decrease to a normal level. A different pressure may be needed for different positions or levels of sleep. Typically, laying on the back and REM sleep promote the worst obstructive sleep apnea. The lowest pressure that controls obstructive sleep apnea in all positions and sleep levels is prescribed.
Effectiveness of CPAP: CPAP has been shown to be effective in improving subjective and objective measures of obstructive sleep apnea.
* It decreases apneas and hypopneas.
* It decreases sleepiness as measured by surveys and objective tests.
* It improves cognitive functioning on tests.
* It improves driving on driving simulation tests and decreases the number of accidents in the real world.
When adjusted properly and tolerated, it is nearly 100% effective in eliminating or reducing obstructive sleep apnea.
An important clinical outcome of CPAP use is in the area of prevention of the potential complications of obstructive sleep apnea. Studies have shown that the proper use of CPAP reduces hospitalization for cardiac and pulmonary causes in people with obstructive sleep apnea. More generally, treating obstructive sleep apnea with CPAP can reduce the risks of conditions related to obstructive sleep apnea, such as, ischemic heart disease, abnormal heart rhythms, stroke, hypertension, and insulin dependence.
Problems with CPAP: The first 2-4 weeks is the crucial time to become a successful CPAP user. During this time, it is important to try to sleep as many hours a night as possible with the mask on. If the mask does not fit properly or the machine is not working it is important to have it fixed immediately. It is also helpful to remember all of the increased risks of untreated obstructive sleep apnea (decreased productivity, heart attacks, strokes, car accidents, and sudden death) as an incentive to continue using CPAP.
People with severe obstructive sleep apnea, never get a normal night of sleep. They often put on the CPAP mask and think it is the best thing ever. They quickly get used to it because it allows them to sleep. They take it on vacations because without it they have no energy and are always sleepy.
However, CPAP is not always easy to use. People with only mild to moderate sleep apnea often have a harder time using CPAP. About 60% of people with CPAP machines report that they use them, but only 45% of them actually use them more than four hours per night when the actual use time is measured. Between 25% and 50% of people who start using CPAP, stop using it.
It is not easy to sleep with a mask that is blowing air into your nose. Some people are claustrophobic and have difficulty getting used to any mask. If a patient has nasal congestion or a septal deviation; it is important to have these evaluated since they can be treated (as discussed later). Some people do not like the inconvenience of sleeping with the mask or traveling with the machine. Others do not like the image of having to sleep with a mask. The noise of the machine blowing air can also be bothersome to some people using the CPAP or their bed partners.
Bi-level positive airway pressure (BiPAP)
Bi-level positive airway pressure (BiPAP) was designed for people who do not tolerate the higher pressures of CPAP. It is similar to CPAP in that a machine delivers a positive pressure to a mask during sleep. However, the BiPAP machine delivers a higher pressure during inspiration, and a lower pressure during expiration, which allows the person not to feel like they are breathing out against such a high pressure, which can be bothersome. It is most helpful for people who require a higher pressure to keep their airway open. BiPAP was designed to improve CPAP compliance; however it is difficult to measure an increase in compliance when compared to standard CPAP. BiPAP is often only approved by insurance companies after documentation that a patient cannot tolerate CPAP.
Auto-titrating continuous positive airway pressure
The auto-titrating CPAP machine is a 'smart' CPAP machine that makes pressure adjustments throughout the night. As discussed above, different pressures are needed for different levels of sleep and positions. The goal of auto-titrating CPAP is to have the lowest possible pressure for each position or sleep level. At a given pressure, if a person starts to have an apnea or hypopnea, the machine adjusts the pressure higher until the episodes are controlled. If a person is in a sleep level or position that doesn't need a higher pressure, the pressure is reduced. The benefit is when a lower pressure is all that is required, the machine is not stuck at the highest pressure needed. The down side is, if the machine does not adjust, a person can be stuck at a lower pressure having episodes of sleep apnea.
With auto-titrating CPAP, the mean pressure throughout the night is lower and 2/3 of the night is spent below the set CPAP pressure. The machine also can adjust for the changes in pressure that are needed to overcome the effects of weight gain and alcohol or sedative use. It may also improve compliance; however, this has not been measured. The disadvantages of auto-titrating CPAP are that leaks may underestimate pressure or airflow.
Dr Abhishek last decade
Apneachoking last decade
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