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Ammunition for a stubborn doctor
#11
When I got mine I started calling the DME a couple weeks before the doctor even sent the order over. I made it clear that I wanted the S9 Autoset. When they finally got the script, I had made good enough friends with the gal in charge of the orders she just gave me the S9 Autoset and they had it all set up in regular CPAP mode. The order from the doctor still said straight CPAP even though I had requested they write it for APAP. They basically just passed along what the sleep clinic results called for.

I believe that ultimately your fate rests with the DME.

When I went back to the doctor a few weeks later I told him I got the top of the line autoset and he thought it was great. He was also very proactive about sleep apnea to begin with and really saved me. I had no idea.
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#12
APAP is at its core a reactive technology; the doc is correct about that. But what he may not be as correct about is the value of APAP.

Technically he is right because APAPs raise pressure based on an event (OA, FL) or series of events. So yes, it does not prevent the original event when pressure had not been yet raised, but raising the pressure in reaction to the original event and then slowly lowering it in the absence of new events has good odds of preventing upcoming events. So while it is reactive from the point of view of the original event, it is also most definitely preventative for a high percentage of successive events.

I think it would be hard to disagree that this is more effective than CPAP, a technology that doesn't even have enough intelligence to BE reactive, let alone preventative of events not addressed by the set pressure. CPAP is not much more than a glorified hair dryer in comparison. CPAP may still be indicated for patients who are sensitive to raised pressure which may trigger centrals, but if you get the settings right that probably is a minor occurrence, and every APAP can be set to CPAP mode anyway for the rare patient that really needs a steady pressure.

But simply being technically correct does not also imply that this is the best thing to say to a patient, or the best prejudice to conform his therapy guidelines to. Based on that, the guy sounds like a tool. A tool you are paying to get this highly-skewed opinion and advice.

The best ammunition is to instruct his office to transfer your records to your new doctor.
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#13
(03-17-2015, 04:06 PM)AirSign Wrote: Am I correct in believing that SA is not a static condition? That over time, the numbers can change?

My argument [at least to myself] includes the idea that I need to keep my next machine for at least 5 years, which is what Medicare at this moment in time says. In 5 years from now, I will have aged 5 years and it's not likely that the body parts which are involved in my sleep apnea will improve.

So, I need a machine that is flexible enough to be useful in the eventuality that my sleep apnea will change in nature, not just in intensity. So unless the doctor can predict with certainty that I won't need a machine that can perform APAP, I want an APAP machine. In the long run, that's prudent and maybe even more cost effective.

The medical mafia want you to have periodic office vi$it$ and have followup $leep $tudie$. Purely
to be $ure that you get the bigge$t benefit$ from your $leep therapy, of cour$e.
Get the free SleepyHead software here.
Useful links.
Click here for information on the main alternative to CPAP.
If it's midnight and a DME tells you it's dark outside, go and check it yourself.
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#14
Thank you for the great advice!
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#15
(03-18-2015, 08:36 PM)TyroneShoes Wrote: Technically he is right because APAPs raise pressure based on an event (OA, FL) or series of events. So yes, it does not prevent the original event when pressure had not been yet raised

I don't think this is correct, at least in the case of my ResMed machine. It also keeps track of flow limitations and raises pressure in response to them. Thus the pressure is likely to start going up well before any actual apnea event.

I can see this behaviour on my graphs. If I set the pressure to pure CPAP at 7 cm. I get a nice low AHI - generally under 1. If I set it to range between, say, 6 and 12 it will start to rise well before I have any events that can be classed as Obstructive or Clear Airway apneas or hypopneas. The AHI isn't really any better.

This appears to be correlated with the start of flow limitations on the flow limitation graph.

A close look at my flow rate graph shows waveforms that are almost all rather flattened on top, and I am fairly sure this has something to do with how the machine behaves.

Ed Seedhouse
VA7SDH

Your brain is not the boss.

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#16
I noticed when helping others with ResMed devices that there are reactions to [other than scorable] events. Such as FL, VS. When someone assets that the "for Her" version is better because it scores RERA, I would just note that the thing that changed is that it counts RERA instead of just reacting to it. [the "for Her" model does react in smaller increments that the base model, and as a result is generally thought to be kinder to the patient. For the same 10 events, this model may up pressure by 3 cmH2O versus the 5 cmH2O of base model.]

The various APAP machines seem to use two forms of reaction - pure surprised reaction -and- predictive reaction. prediction is based on seeing pre-cursor (unscored) events, followed by quick adjustment to prevent scorable events. CPAP, one-setting machines have no predictive or reactive components, and run with no interest in the patient's actual condition, besides the prediction that what happened one night in a sleep lab will continue to characterize patient condition for short or long term future (regardless of recovery brought about by therapy).

What remains is a comparison - [a properly adjusted CPAP] versus [a well tuned APAP]. That is talked about elsewhere, but there is some rationale to finding your sweet spot, then dwelling there. It can make both of these much better than black box set pressures or wide-open adjusting pressures.

Getting a properly adjusted CPAP out of a single sleep lab titration is highly improbable. Dont-know

QAL
Dedicated to QALity sleep.
You'll note I am listed as an Advisory Member. I am honored to be listed as such. See the fine print - Advisory Members as a group provide advice and suggestions to Apnea Board administrators and staff concerning Apnea Board operation and administrative policies. Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.
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#17
Not highly improbable just hit or miss. We keep berating the sleep labs about their single session approach to diagnosis and titration but it is not the Sleep lab's fault if the patient can't sleep or can't sleep well and most of the things that can be done to help the patient sleep may affect the results. The home sleep study is an alternative but it is not as definitive. In many cases, it seems to me that we are leaving it up to the sleep specialist MD to make his or her best educated guess what the therapeutic variables should be. This sounds to me like a good argument for APAPs for all and good patient follow up.

Best Regards,

PaytonA
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#18
I agree with PaytonA on this one.
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#19
The scrip for the machine does not need to be written by the sleep doctor. If you have a good relationship with your GP he can write it the way you want for the machine you want, and the DME can fill from that.
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#20
(03-19-2015, 01:10 PM)eseedhouse Wrote:
(03-18-2015, 08:36 PM)TyroneShoes Wrote: Technically he is right because APAPs raise pressure based on an event (OA, FL) or series of events. So yes, it does not prevent the original event when pressure had not been yet raised

I don't think this is correct, at least in the case of my ResMed machine. It also keeps track of flow limitations and raises pressure in response to them. Thus the pressure is likely to start going up well before any actual apnea event.
...

Well, I think you are right, but I think we are both right, because that is very close to what I actually said, in context. My Autoset acts (REacts in response, actually) probably in the exact same manner as yours does, something I am quite familiar with. You might have noticed that I mentioned FL as an example directly in my post, which you quoted. And maybe you did not notice that, or some other things that I also covered.

But APAP does not raise pressure to prevent a FL; it raises pressure reactively to a FL. And just like how it reacts to a OA event, it does nothing about that event other than REACT to it by changing pressure after the fact to help the odds of preventing successive events.

I am defining "event" here as anything not kosher with the regular, normal pattern of healthy respiration, and not just restricting it to OA/CA/H events that are long enough or severe enough to be flaggable. So a FL is an event also, if you follow that logic, even though it is not flagged as an apnea. I am also including "undefined" apneas as well as the user-flagged events from SleepyHead, also events that APAP might REACT to.

APAP does not have a crystal ball, and can't predict actual events and fix them directly, only raise pressure in response to them in hopes of preventing future events that it also can't predict. By the time an OA event is long enough to be recognized as such and flagged accordingly, it is essentially already over. The boat has sailed. Without a time machine function, no xPAP technology can go back and prevent an event, because it does not know about it until it is over, and you can only REACT to something that is over. PROactivity is not an option.


So APAP is indeed reactive (doc's correct about that), as well as preventative (doc's incorrect about that), but only preventative regarding successive events. The term you used above, "in response" refers to a reactive process, by definition.
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