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Maybe I have apnea, maybe not, are all sleep doc jerks?
#21
RE: Maybe I have apnea, maybe not, are all sleep doc jerks?
CM said 

Quote:Now, the BIG question... How do you feel?

That is a serious question.  We care as much (actually more) about how you feel than we do about the numbers
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#22
RE: Maybe I have apnea, maybe not, are all sleep doc jerks?
(03-28-2021, 04:09 PM)Gideon Wrote: CM said 

Quote:Now, the BIG question... How do you feel?

That is a serious question.  We care as much (actually more) about how you feel than we do about the numbers

Yeah, I know it's a serious question, but I'm not sure how much better I feel. I have arthritis and carpal tunnel and am in pain anyway. Even with the collar I have lots and lots of flow limits and the pressure doesn't really seem to make much difference. I have a fitbit which I think is reasonably good at detecting sleep stages. (I was wearing it during my sleep study. It missed most of the dozens and dozens of arousals, but it did nail every transition between light and deep nREM and REM sleep.) According to my fitbit, long-term I only have 6-8% of my sleep as deep. (Last night I had zero minutes of deep sleep.) I think that women my age (58) typically don't get enough deep sleep.

I don't usually need to pull over to avoid falling asleep while driving, but sometimes I do. I sometimes doze off at the dinner table when other people are talking, but not while I'm talking.

So, yeah, I dunno...
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#23
RE: Maybe I have apnea, maybe not, are all sleep doc jerks?
Well yesterday they called with the results of my sleep study from last week. Short version -- the sleep study that I had last week and the sleep study that I had in November look like two different people! (I swear it was me both times, LOL).

So the purpose of the study was to test the notion that my November study had little sleeping on my back, and that's why it was so uneventful. My assignment was to stay on my back as much as possible, which I apparently managed to do for the first 3/4 of the night.

What is most striking to me is that I remember things happening in a particular order and approximate lengths of time, but according to the data in the report a lot of what I "remember" simply didn't happen, or didn't happen the way I remember it. I think that I  simply do not have the ability to judge time when I'm moving in and out of sleep. Which is good to know because I now have a healthy skepticism about my ability to "remember" what happened when I am looking at my OSCAR data of sleep at home.

Ok, the bottom line -- last November I had a supine AHI of 7, non-supine of 2, min SpO2 of 93%, and the conclusion was that I don't have apnea. Last week I had a supine AHI of 13 (NREM 11, REM 42) -- but a non-supine AHI of freaking 39, and all of that was in NREM sleep because I got no REM sleep on my side. (I had ALL of my REM sleep on my back, first with a block of REM interrupted multiple times. Then later I got rudely pitched from REM to awake by a hypopnea after just a couple of minutes of REM.)

Maybe this was all chin-tucking, whether on back or side?

So I think what I saw here is that sleep study data may be very broad and measuring all sorts of sophisticated things in sophisticated ways, but it's just one night. In comparison, the data saved by the cpap machine is much more limited (just breathing), but it's data taken every night, all night, night in and night out, over years. So I "failed" my sleep study, and that succeeded in getting my insurance to pay for therapy -- which gives me the tools to collect my own data over the long haul, which can tell me if what I am trying is working or not.

What I'm looking for in particular is a more advanced machine, even if it's just a later version of the A10. I'm pretty sure that the machine I have was one of the first A10s that came off the assembly line after they went into production quantities. My first night of use was Oct 10, 2014, and the machine was powered on and tested on Sept 10, 2014. (There was an empty Datalog/20140910 folder on the card when I got the machine.) I had to wait 6 weeks after getting my prescription for the DME to get it in (not fun with newly-diagnosed untreated apnea) so I wasn't willing to wait another 2-3 months for the "For Her" model. And I think that the recent models score RERAs which my machine has no concept of. And are we expecting ResMed to come out with some new technology soon? Specifically related to flow limitations? For now I'm fine with using the data I can get from the machine I have, and hope to get a new machine in the next couple of months. (Fortunately the way that my insurance works is that they don't require rent-to-own for established cpap users.)

Here's the data summaries, with November on the left, April on the right:
   

The hypnograms:
   

And the microarousals, leg movements & heart rates:
   

(The blue-background graphs are from my Fitbit's sleep metrics -- which I'm trying to decide the accuracy of. The heart rate graph looks spot on with both studies, and I'm pretty sure that the 48 bpm that the sleep study showed at ~10pm last week must have been a loss of signal with the pulse-ox and not anything real. My FitBit loses my heart rate signal for random short periods all the time, and has some software that interpolates over brief interruptions.)

Here's the text narrative of last week's study:

Quote:TECHNOLOGIST COMMENTS: Pt here for repeat psg post cpap trial. She's lost >100# after starting cpap in 2014. Test is ordered psg with pt sleeping supine. Respiratory events scored using 3% rule as her insurance is with UMR. Sleep fragmentation noted. Long period of wake after 03:00. OSA noted and also supine REM noted. Snoring ranged from mild to moderate @ times. As test was ordered psg no cpap applied.

SUMMARY OF SLEEP DATA:

1) Baseline Vital Sign Data Awake:
- Respiratory rate 13 breaths per minute, pulse oxyhemoglobin saturation (SpO2) 95%, and heart rate 83 beats per minute.
- Height of 67 in, weight of 151 lb and BMI of 24. Neck circumference (if availalbe) of 13 in.

2) Sleep Architecture:
- The study start time was 20:20 hours and the study end time was 05:32 hours. Lights Out occurred at 20:58 hours and Lights On at 04:56 hours. A total of 355 min. of Total Sleep Time (TST) were recorded in 477 min. of Total Recording Time (TRT) resulting in a Sleep Efficiency of 74.5%. Once sleep onset occurred, Sleep Maintenance was 76%. Sleep Stages were distributed as follows (% of TST): 11% NREM 1, 76% NREM 2, 6% NREM 3 and 6% REM sleep. A total of 113 min. of Wake After Sleep Onset (WASO) was seen once sleep onset had occurred.

3) Sleep Latencies:
- Sleep onset was NREM 1 sleep, which first occurred 6 minutes after lights out. REM sleep was first observed 165 minutes after sleep onset.

4) Arousal and Awakening Data:
- A total of 9 awakenings and 122 arousals were seen across the night resulting in a mean of 21 arousals and 1.5 awakenings per hour of sleep. A mean of 18 arousals per hour of sleep were related to respiratory events, 0.0 arousals per hour of sleep were related to periodic limb movements, and the remainder without particular cause.

5) Sleep-related Respiratory Patterns:
- A total of 0 apneas (0 obstructive, 0 mixed, 0 central), 106 hypopneas (106 Obstructive and 0 Central), and 0 respiratory event related arousals (RERAs) were observed in 355 minutes of total sleep time.
- Apneas lasted a mean of 00 seconds (OA, MA, CA) and as long as 00 seconds. Hypopneas lasted a mean of 30 seconds and as long as 74 seconds.
- The mean number of apneas and hypopneas per hour of sleep was 18 per hour of sleep.
- If respiratory event related arousals (RERAs) were also scored, the respiratory disturbance index (RDI), the mean number of apneas, hypopneas and RERAs per hour of sleep was 18 per hour of sleep.
- The lowest oxyhemoglobin desaturation (SpO2) related to a respiratory event was 86% associated with a 41 seconds obstructiveHypopnea.
- RDI supine was 13 per hour and lateral RDI 39 per hour of sleep. During REM sleep- REM RDI was 42 per hour, NREM RDI 16 per hour, REM supine RDI 42 per hour, and NREM supine RDI was 16 per hour of sleep.

6) Oxyhemoglobin Saturation Data (Desaturation Threshold 4):
- The average oxyhemoglobin saturation breathing room air awake was 95%. The average during NREM sleep was 94%; 93% during REM sleep. The total oxyhemoglobin desaturation index was 8 per hour of sleep.
- The lowest oxyhemoglobin desaturation (SpO2 nadir) was 86% in NREM sleep and 87% in REM sleep. A total of 0.4 minutes of the recording time was spent with an oxygen saturation of 88% or less
- The 3% desaturation threshold: The 3% oxyhemoglobin desaturation index was 18 per hour of sleep. There were 112 3% oxygen desaturations recorded with 16 during REM sleep, 92 during NREM sleep and 4 during wake. There were 67 (14 per hour of sleep) in the supine position and 45 (44 per hour of sleep) while non-supine.
- The 4% desaturation threshold: The 4% oxyhemoglobin desaturation index was 8 per hour of sleep. There were 52 4% oxygen desaturations recorded with 11 during REM sleep, 37 during NREM sleep and 4 during wake. There were 31 (5 per hour of sleep) in the supine position and 21 (21 per hour of sleep) while non-supine.
- The 5% desaturation threshold: The 5% oxyhemoglobin desaturation index was 4 per hour of sleep. There were 29 5% oxygen desaturations recorded with 5 during REM sleep, 22 during NREM sleep and 2 during wake. There were 17 (3 per hour of sleep) in the supine position and 12 (12 per hour of sleep) while non-supine.

7) Heart rate data: Periods of Tachycardia were observed
- The average heart rate during wakefulness was 83 beats per minute (bpm) with a minimum heart rate of 64 bpm and a maximum of 109 bpm.
- The average heart rate during sleep was 77 bpm with a minimum of 48 bpm and a maximum of 97 bpm.
* The average heart rate during NREM sleep was 76 bpm with a minimum heart rate of 48 bpm and a maximum of 97 bpm.
* The average heart rate during REM sleep was 84 bpm with a minimum heart rate of 72 bpm and a maximum of 92 bpm.

8) Periodic Limb Movements: A mean of 0.0 periodic limb movements per hour of sleep noted (PLM-I); a mean of 0.0 per hour of sleep caused arousal (PLM-ArI).

9) Excessive Motor Activity/Parasomnia/EEG abnormalities: No excessive motor activity, parasomnias, EEG abnormalities or loss of REM
sleep atonia was observed.

For comparison, last November's study:
Quote:TECHNOLOGIST COMMENTS: This patient was referrd by Dr. W. and study will be interpeted by Dr. G. The AASM hypopnea 3% scoring rule was used. The patient has insurance with UMR. Patient arrived to sleep lab by self and was in stable condition.  Patient had a sleep study done about 6 years ago she said and had OSA. Patient sleeps with CPAP machine at home every night since.  Patient has lost over 125 pounds since 2015. Patient has a ESS of 16 and a neck size of 13. Patient did not initiate sleep easily. During study  the patient was noted for light snoring, apnea, hypopneas, and arousals. PSG performed and split night not met. Worse in Supine position.  Patient slept on left and right side as well. Sp02 100-93%. Patient was pretty restless throughout the night and tossed and turned.

SUMMARY OF SLEEP DATA:

1) Baseline Vital Sign Data Awake:
- Respiratory rate 13 breaths per minute, pulse oxyhemoglobin saturation (SpO2) 96%, and heart rate 77 beats per minute.
- Height of 67 in, weight of 144 lb and BM1 of 23. Neck circumference (if availalbe) of 13 in.

2) Sleep Architecture:
- The study start time was 20:04 hours and the study end time was 04:51 hours. Lights Out occurred at 20:44 hours and Lights On at 04:31  hours. A total of 361 min. of Total Sleep Time (TST) were recorded in 466 min. of Total Recording Time (TRT) resulting in a Sleep Efficiency  of 77.5%. Once sleep onset occurred, Sleep Maintenance was 80%. Sleep Stages were distributed as follows (% of TST): 3% NREM 1, 72%  NREM 2, 7% NREM 3 and 18% REM sleep. A total of 89 min. of Wake After Sleep Onset (WASO) was seen once sleep onset had occurred.

3) Sleep Latencies:
- Sleep onset was NREM 1 sleep, which first occurred 15 minutes after lights out. REM sleep was first observed 158 minutes after sleep onset.

4) Arousal and Awakening Data:
- A total of 13 awakenings and 51 arousals were seen across the night resulting in a mean of 8 arousals and 2.2 awakenings per hour of sleep. A mean of 1 arousals per hour of sleep were related to respiratory events, 0.0 arousals per hour of sleep were related to periodic limb movements, and the remainder without particular cause.

5) Sleep-related Respiratory Patterns:
- A total of 3 apneas (2 obstructive, 0 mixed, 1 central), 9 hypopneas (9 Obstructive and 0 Central), and 9 respiratory event related arousals (RERAs) were observed in 361 minutes of total sleep time.
- Apneas lasted a mean of 13 seconds (OA, MA, CA) and as long as 13 seconds. Hypopneas lasted a mean of 24 seconds and as long as 48 seconds.
- The mean number of apneas and hypopneas per hour of sleep was 2 per hour of sleep- If respiratory event related arousals (RERAs) were also scored, the respiratory disturbance index (RDI), the mean number of apneas, hypopneas and RERAs per hour of sleep was 3 per hour of sleep.
- The lowest oxyhemoglobin desaturation (SpO2) related to a respiratory event was 92% associated with a 19 seconds obstructiveHypopnea.
- RDI supine was 26 per hour and lateral RDI 2 per hour of sleep. During REM sleep: REM RDI was 3 per hour, NREM RDI 2 per hour, REM supine RDI 0 per hour, and NREM supine RDI was 4 per hour of sleep.

6) Oxyhemoglobin Saturation Data (Desaturation Threshold 4):
- The average oxyhemoglobin saturation breathing room air awake was 96%. The average during NREM sleep was 95%; 95% during REM sleep. The total oxyhemoglobin desaturation index was 0 per hour of sleep.
- The lowest oxyhemoglobin desaturation (SpO2 nadir) was 93% in NREM sleep and in REM sleep. A total of 0.0 minutes of the recording time was spent with an oxygen saturation of 88% or less
- The 3% desaturation threshold: The 3% oxyhemoglobin desaturation index was 0 per hour of sleep. There were 3 3% oxygen desaturations recorded with 1 during REM sleep, 2 during NREM sleep and 0 during wake. There were 1 (2 per hour of sleep) in the supine position and 2 (0 per hour of sleep) while non-supine.
- The 4% desaturation threshold: The 4% oxyhemoglobin desaturation index was 0 per hour of sleep. There were 1 4% oxygen desaturations recorded with 0 during REM sleep, I during NREM sleep and 0 during wake. There were 1 (0 per hour of sleep) in the supine position and 0 (0 per hour of sleep) while non-supine.
- The 5% desaturation threshold: The 5% oxyhemoglobin desaturation index was 0 per hour of sleep. There were 0 5% oxygen desaturations recorded with 0 during REM sleep, 0 during NREM sleep and 0 during wake. There were 0 (0 per hour of sleep) in the supine position and 0 (0 per hour of sleep) while non-supine.

7) heart rate data: Periods of Tachycardia were observed
- The average heart rate during wakefulness was 77 beats per minute (bpm) with a minimum heart rate of 67 bpm and a maximum of 103 bpm.
- The average heart rate during sleep was 73 bpm with a minimum of 62 bpm and a maximum of 91 bpm.
* The average heart rate during NREM sleep was 72 bpm with a minimum heart rate of 62 bpm and a maximum of 91 bpm.
* The average heart rate during REM sleep was 77 bpm with a minimum heart rate of 68 bpm and a maximum of 87 bpm.

8) Periodic Limb Movements: A mean of 0.7 periodic limb movements per hour of sleep noted (PLM-I); a mean of 0.0 per hour of sleep caused arousal (PLM-ArI).

9) Excessive Motor Activity/Parasomnia/EEC abnormalities: No excessive motor activity, parasomnias, EEG abnormalities or loss of REM sleep atonia was observed.

(Note that the studies were done by different technologists, and this is a sleep lab in my small town's one hospital. The sleep medicine is all coordinated out of the big flagship hospital in the system.)

Something that is puzzling to me is RERA seems to mean different things in the two studies -- is that not a well-defined thing? In this study I had only Obstructive Hypopneas -- 106 of them -- and 106 "Arousals- Resp Events" and that gave me an RDI, AHI, OAHI, and HI that are all the same, but somehow none of that counts as a RERA? My ResMed machine has spent the last 6.5 years chasing Flow Limits basically every sleeping minute that I'm not in an Apnea/Hypopnea or awakened by my flow limits. But this sleep study doesn't notice anything interesting going on between the scored hypopneas?

Any thoughts?
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#24
RE: Maybe I have apnea, maybe not, are all sleep doc jerks?
I believe it was at least mostly, chin tucking, look at April's Apnea/Hypopnea chart. The 'tell' of clustering is there at a level that any duck should be able to see it. I didn't see anything about it in the write-up.
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#25
RE: Maybe I have apnea, maybe not, are all sleep doc jerks?
While we have become very accustomed to the clustering pattern, the docs don't understand positional apnea in anywhere near the same context as we do, as a consequence of chin-tucking. They are all convinced that it is the patient sleeping on their back and obstructing on their floppy tongue and throat tissues. Here we have a relatively thin subject the experienced a significant higher rate of apnea on her side rather than on her back. This not only confirms our assertions of the Positional Apnea wiki, it completely flies in the face of the conventional sleep medicine practice. The problem is not that the doctors don't recognize it, it is that they are not even curious to understand it.

With regard to a more advanced machine, the Resmed Aircurve 10 Vauto is the clear choice to further reduce flow limitations and respiratory effort related arousals (RERA). The sleep study notes 39 RDI events per hour, and the Oscar charts show characteristic flow limitation at many times through the night. The image below clearly illustrated the problem that would be resolved by more pressure support with the Vauto that is not resolved with the CPAP EPR. I won't give the doctor credit for recognizing or acknowledging this problem, but it can be fully resolved by higher pressure support and avoid the arousals we see at 22:46:40 and 22:50:40. About the only shot at obtaining an advanced machine is to focus on the high RDI in your test and showing how these events persist in CPAP, with the clear understanding these flow limitations that give rise to to respiratory arousals is better resolved with pressure support, rather than pressure. Good luck!

[Image: attachment.php?aid=31097]
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#26
RE: Maybe I have apnea, maybe not, are all sleep doc jerks?
Set your PS=5 and see what you get
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#27
RE: Maybe I have apnea, maybe not, are all sleep doc jerks?
Ok, to return to the third part of my subject title -- about sleep doctors being kind of a-holes...

My whole experience of sleep medicine has been that there is a pretty strong thread of "scam" that runs through the whole thing. Along with strong counter-currents of bullying doctors-who-think-they-are-gods.

I frequently start with the observation that sleep medicine is a place where the language of the discipline uses the word "compliance" to characterize "decisions" that patients make when they are freaking unconscious!

When I started on this, my PA wrote my prescription based upon the recommendation of some nameless, faceless sleep doctor at the "sleep center" associated with the flagship hospital of the system that my little town's single hospital is a part of. I did some internet research, found out about sleepyhead, decided I needed one of the brand-new ResMed AirSense10 machines which were just coming out. I suspected that I needed the ForHer, but that was on even longer back order than the base model, and I took what I could get.

I quickly figured out that I was on my own, and nobody who was being paid for "providing" sleep "therapy" was going to do anything other that sell me supplies at the insurance-mandated intervals. As to WHICH mask, and even which size, I had to figure it out. Pugsy over at [[ Auto Word Filter: links to DME-owned sites not allowed ]] was a huge help. Also got there the excellent advice to fly under the radar, don't tell anybody that you are changing your own settings. My PA has always been totally open that I know more than she does about this, and I've been through multiple DMEs so don't really care what the RTs think (Lincare will make anybody jaded!)

All along I've been doing research, and looking at my data, and there has always been this disconnect between my own experience and what info I can find. I am most puzzled by flow limitations. My own experience is that if my machine reports a flow limitation of zero for more than a handful of breaths in a row, then that means one of only two things:
  1. I'm awake.
  2. My Flow Rate graph is heading into, heading out of, or is in the midst of, an apnea or a near-apnea -- so it's the flat of the apnea, or the wild gyrations on either side of an OA, or it's a CA.
My interpretation is that everyone's model is "flow limits are a leading indicator of an impending event, and the machine raises the pressure and that prevents the event." But what I see is that this model is completely false for me. Detected flow limits for me simply mean that I'm asleep. I have a very low AHI except for very isolated incidents of complete sh*t-show clusters, and over the last 6-1/2 years I have weeks/months between those clusters. When those clusters appear there is nothing in the Flow Limitations those nights that are in any way distinguishable from the constant flow limitations that I have on normal nights. If I leave the machine wide open, it will chase those flow limits all night -- I'm asleep and the pressure rises, I wake up it goes down. If I set the max pressure very low -- i.e. I don't allow the machine to chase those flow limits -- then the machine pegs at the set max, but I don't get events. In other words, the flow limits are not leading indicators of impending events. And when I do have one of those rare nights with clusters, the surrounding flow limit behavior doesn't look any different from all of those nights when I have no events or just a few events.

And now I have figured out the chin-tucking thing, and I can explain the clusters. So again I'm back at seeing my normal, night-in-night-out, continuous FLs while asleep, NOT leading to any events, and concluding that -- for me -- my sleep-disordered breathing is the flow limits themselves, and those wild clusters are a separate thing. Looking at my data, what I think I'm seeing is that I have UARS all of the time (sucking air through a coffee stirrer when asleep) and as a totally separate issue I'm always in danger of positional apnea unless I use a device (cervical collar) that can control chin tucking without me needing to be awake. (And here we are back at me being P*ssed off about the word "compliant" where they expect me to simply decide to have a good sleep posture even though I am freaking unconscious.)

So, to come to the end of that really long explanation, I think that my case ought to be incredibly interesting to any sleep doctor who cares about the actual science of sleep disordered breathing. I'm really wondering if those unicorns really exist...

And I'm back at more subtle questions -- should I care about FLs that don't lead to apneas/hypopneas? The main reason that I'm worried is the tachycardia. I'm becoming more and more convinced that what the flow limits are doing is -- over a very long time frame -- damaging my health in subtle ways that are building up.
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#28
RE: Maybe I have apnea, maybe not, are all sleep doc jerks?
Yes Apnea doctors go quack a lot. You MUST self advocate or you're left with untreated or less than optimal treatment but think that since doc is satisfied you're OK. But doc isn't the one with Apnea that needs to mask up nightly.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#29
RE: Maybe I have apnea, maybe not, are all sleep doc jerks?
Flow limits are an indication of inspiratory effort that fails to achieve the optimal flow rate of air. This effort, as shown in the example above, results in arousals and fatigue. The use of pressure support can overcome the resistance of a small airway. In this case "pressure support" is a descriptive term. Starting inspiration, pressure support builds behind the breath and helps maintain a higher flow rate as inspiration progresses, then it drops off as exhale begins. You experience it to a limited extent with your Airsense 10. You could try using your machine with no EPR or a setting of 1 and compare that with a setting of 3. Needless to say, a setting of 3 is much more comfortable and facilitates easier inspiration with lower flow limits. If you try this the difference will be noticeable. With bilevel, you're not limited to 3-cm of pressure support. This is the kind of demonstration that might be persuasive to a doctor, although I don't think many of them have any real interest in this line of work, and it is secondary to their primary practices. Most sleep doctors do this as an easy source of extra income, signing sleep reports, and focus on their specialties and regular practice. The system is broken as you know.
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www.ApneaBoard.com

____________________________________________
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#30
RE: Maybe I have apnea, maybe not, are all sleep doc jerks?
Ok, my history with pressure support is also "interesting" (by which I mean I'm stupid, LOL). Back at the beginning I tried to leave the EPR at 3 and found it gave me this weird "throbbing" sensation, so I concluded that it was stupid and turned it off. At the very beginning I found that every "comfort" feature that I was allowed to control from the patient side of the menu made me less comfortable. Ramp sucked. EPR was like  fingernails on chalkboard. The dry air woke me up, and the heated air made me miserable. (I was right at menopause, and was keeping my office temperature at 58, and working in shorts, t-shirt and bare feet. One night I tried to turn the humidity all the way up and the temperature all the way down and woke up with a deluge in my mask LOL!) Now you see why I've been angry and cranky about the stupid machine and the idiots who are supposed to be providing "therapy" all the way back to the beginning.

So, yeah, I actually have six+ years of data with no pressure support at all, and I don't think that I can really make an argument that the EPR of 3 is working better than the EPR turned off. Here's what I think is a reasonably representative comparison:

   

The top is two days ago, wearing a cervical collar. The bottom is 3 days after my sleep study last November with the settings that I ran for years.

And I still think that there is something funky about the way that the machine is logging the flow limits. One thing is that I wonder if the time stamp is at the end of the calculated period looking backwards (like the events) because I can see after dumping the data in a spreadsheet that it's on the graph with the value running from the time stamp to the next time stamp and there are lots of funky regions where it seems like the data better matches in the other direction. Or maybe not -- perhaps it's just weaknesses in the algorithms? When I see stuff like this:

   

I'm thinking that where the pressure is dropping on the left side of the apnea, the algorithm shouldn't be calling that a zero FL, and shouldn't be dropping the pressure, and during the actual OA when the pressure is rising and the algorithm is reporting zero, calling a 16-second OA a zero flow limitation doesn't make a lot of sense.

I wonder if I could rent an ASV for a month and see what a PS of 5 or 6 would do for me? What I'm seeing in that last picture is that the ResMed algorithm seems to be overwhelmed with what I've got going on and it's just kind of lost...
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