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ResMed S9 Elite -- MANY apnea events still
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jcarerra Offline

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Post: #1
ResMed S9 Elite -- MANY apnea events still
I am only one week into CPAP use...was provided a ResMed S9 Elite. A couple of days ago, I got software that lets me see the SD card data.

What a shock. The machine is not stopping the apnea, and frankly I am a bit scared. There was approximately a two hour period last night of obstructive apneas (one central) at a rate of over one per minute--duration generally between 15 and 30 seconds.

Then I looked at the pressure line and found it unchanging at 12cm! Phone call to the equipment supplier, and I discovered Elite does not try to clear an obstructive apnea (save your life) by increasing the pressure! Holy you know what Batman.

The supplier said that is "what the doctor ordered" and they cannot change it. Also that Medicare rules for the ones that DO adjust pressure as needed are very stringent.

Any suggestions on how to proceed would be welcome.
06-06-2014 07:25 PM
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Peter_C Offline

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Post: #2
RE: ResMed S9 Elite -- MANY apnea events still
First, others will jump in shortly with more/better info. Can we get a bit more info please? AHI numbers, leak rate numbers, etc?

*IF* you are really concerned, you may wish to invest in a 'recording Oximeter', cost is like $80 to $140 or so, and it even has an alarm that can be set to wake you if your blood O2 drops below a certain number (set by you).

Usually you are scheduled with a follow-up visit with your sleep doc to discuss what's going on a month or so after you start with your machine. Also, it can take many people weeks/months to get used to both their machine and see benefits.

It would be good to learn from you what your untreated AHI was, and then see what it is currently while on your machine.

FYI? My OSA is/was/still is very severe. Even after both nose and throat surgery, my non-machine study numbers were in the high 90s (as in at least 90 events per hour with at least a 15 second stoppage). My AHI on my dream machine bounces from a (rare low of 4-5, and a high of 10-15) and I am both happy and feel so much better - in other words it is a matter of degree. The magic goal everyone shoots for is an AHI of less than '5' every night. Keep in mind, if your leak rate is not under control, all numbers are suspect.

*I* am not a DOCTOR or any type of Health Care Professional. My thoughts/suggestions/ideas are strictly only my opinions.

"Only two defining forces have ever offered to die for you. Jesus Christ and the American Soldier. One died for your Soul, the other for your Freedom."
06-06-2014 07:41 PM
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diamaunt Offline

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Post: #3
RE: ResMed S9 Elite -- MANY apnea events still
no cpap changes pressure, that's the "continuous" part of Constant Positive Airway Pressure... (corrected)

if you want something that adapts to you, you need an APAP

you might discuss with your doctor whether you need to up the pressure a bit.... (I certainly can't recommend you do what I did, and do it yourself).

also, good deals on used apaps can be found on craigslist.
(This post was last modified: 06-06-2014 08:23 PM by diamaunt.)
06-06-2014 07:44 PM
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zonk Offline

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Post: #4
RE: ResMed S9 Elite -- MANY apnea events still
(06-06-2014 07:25 PM)jcarerra Wrote:  The supplier said that is "what the doctor ordered" and they cannot change it. Also that Medicare rules for the ones that DO adjust pressure as needed are very stringent.

Any suggestions on how to proceed would be welcome.
My understanding, Medicare rules are the same of CPAP or APAP, they pay the same amount for either machines and both are billed by the same billing code E0601
Did the doc wrote for the script for S9 Elite? the doc should write "S9 AutoSet pressure range 10-15 (just an example) and dispense as written

AHI is average per hour, you might have some events at some times and none at other times
WHats AHI, AHI 5 or below is normal while on PAP
Is leak below the red line (24 L/m) for most of the night?
06-06-2014 07:45 PM
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diamaunt Offline

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Post: #5
RE: ResMed S9 Elite -- MANY apnea events still
(06-06-2014 07:41 PM)Peter_C Wrote:  *IF* you are really concerned, you may wish to invest in a 'recording Oximeter', cost is like $80 to $140 or so, and it even has an alarm that can be set to wake you if your blood O2 drops below a certain number (set by you).

you can get a perfectly servicable CMS50D+ (the plus is important) for 50$ from amazon.... less from other places.

the best price I found on them was about 30$ from aliexpress/alibaba in china, I just received a CMS50I from them, cost me 90$ delivered... it's the wrist mounted model that has a clock in it and records multiple sessions.... handy.

using it on a friend that's got CHF and is on 2lpm o2 at night, make sure he stays pink and happy and doens't turn blue and sad during the night.
06-06-2014 07:59 PM
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trish6hundred Offline

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Post: #6
RE: ResMed S9 Elite -- MANY apnea events still
Hi jcarerra,
WELCOME! to the forum.!
Hang in there for more responses to your post and best of luck to you with your CPAP therapy.

trish6hundred
06-06-2014 08:13 PM
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PaytonA Online
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Post: #7
RE: ResMed S9 Elite -- MANY apnea events still
(06-06-2014 07:44 PM)diamaunt Wrote:  no cpap changes pressure, that's the "constant" part of Constant Positive Airway Pressure...

if you want something that adapts to you, you need an APAP

you might discuss with your doctor whether you need to up the pressure a bit.... (I certainly can't recommend you do what I did, and do it yourself).

also, good deals on used apaps can be found on craigslist.

Just to be clear here, the C in CPAP stands for continuous. So an APAP is actually an auto CPAP or more correctly an auto titrating CPAP.

A plain vanilla CPAP is a constant CPAP.

Best Regards,

PaytonA
06-06-2014 08:19 PM
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jcarerra Offline

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Post: #8
RE: ResMed S9 Elite -- MANY apnea events still
Just discovered all these great answers, but have 0730 breakfast meeting in AM, so will just hit a few backfeeds here, then will be back on late morning of 6-7...

AHIs mostly in 10-12 range, remember one 7.x one 2.x.
I don't like AHI because you can have 6-7 hours of good data but 1-2 hours of near death and still have an acceptable AHI. It is an average that includes the "no problem" periods, which skews the number.

Leak rate is fine--minor, except when I take it off for potty break..

I understand the quibble over the acronym--I think most people call ANY "give you air while you sleep" machine a CPAP, whether it varies the level or not. Even the ones that vary the level seldom lower the pressure to zero, therefore technically they are indeed correctly called CONTINUOUS---there is continuous pressure (as opposed to Constant Level). I don't get hung up over that.,

I have not learned all the other abbreviations/acronyms for functions, data elements, etc. OSA? Quite the lingo here. Learning curve at hand and communication impacted until that is over.

More tomorrow==sorry must get sleep for early (for me) rise.
(This post was last modified: 06-06-2014 09:00 PM by jcarerra.)
06-06-2014 08:59 PM
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robysue Offline
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Post: #9
RE: ResMed S9 Elite -- MANY apnea events still
(06-06-2014 07:25 PM)jcarerra Wrote:  I am only one week into CPAP use...was provided a ResMed S9 Elite. A couple of days ago, I got software that lets me see the SD card data.

What a shock. The machine is not stopping the apnea, and frankly I am a bit scared. There was approximately a two hour period last night of obstructive apneas (one central) at a rate of over one per minute--duration generally between 15 and 30 seconds.

With an Elite at least you have the data that let's you KNOW your therapy is not yet effective.

Just imagine what would be going on if you'd been set up with an S9 Escape: You'd still be feeling lousy, but no one---not you, not the DME, and not the doc, would be able to tell that the problem was that your AHI is still too high and that you are still having clusters of events and that you are NOT leaking. And for the first several months, the doc would likely be telling you nothing but, "It takes time. Just keep trying."

It can take months for a patient with an Escape to finally figure out that something is terribly wrong and get a proper diagnosis of what the real problem with their therapy is.

Quote:The supplier said that is "what the doctor ordered" and they cannot change it. Also that Medicare rules for the ones that DO adjust pressure as needed are very stringent.

The supplier is correct when they say they can't change the pressure: They set the machine to what the doctor wrote in his script and they are NOT allowed to change the settings without further instructions from the doc.

The supplier is NOT correct when they say Medicare rules for getting an APAP are more stringent than Medicare rules for getting a CPAP: Every APAP and CPAP is billed under the same insurance code, and that's the code that Medicare uses. So if you've got a script for a CPAP set at n cm, all it takes to get an APAP is a cooperative supplier (or DME as they're called around here.)

A really useful blog enrty for you to look at would be What you need to know before you meet your DME on a blog called Mask Arrayed.

Quote:Any suggestions on how to proceed would be welcome.
You do have some choices:

You can pester your doctor with phone calls and bring in a printout of the data that shows your AHI is still too high. Depending on the doc, he'll likely do one of the following things:
  • Tell you the AHI may (or should) come down in a week or two, and to let him know if it doesn't. There are many people who do have AHIs in the 10-20 range during the first few days, but the AHI then quickly drops into the normal range and there's nothing else that really needs to be done.
  • Order a pressure increase on your Elite. Depending on how closely the doc looks at the detailed data vs. the summary data and how high the AHI is, he may order a minor pressure adjustment of 1-2 cm or (much more rarely) he may decide to increase the pressure by 3-4 cm
  • Order a temporary switch to an Auto CPAP for a week or two of autotitration and decide what to do after looking at the data. He'll fax a script over to the DME who will lend you an APAP for the autotitration; you'll be expected to keep your Elite in reserve. The APAP will most likely be set wide open (4-20) during the autotitration. At the end of the autotitration the doc looks at the data. Most likely he'll send a script to the DME telling them to change the pressure on your Elite to the 95% pressure level on the two weeks worth of auto titration data. And then the Elite, with its fixed pressure changed, takes over once again as your new machine.
  • Order/request a permanent switch to an Auto CPAP and send a script for the appropriate auto range to the DME. The DME will then swap out your machine. They may squawk loudly about doing this, but if the script is permanently changed, they'll have to honor the new script. And hopefully you'll start with a fresh S9 AutoSet instead of an S9 Escape Auto.

OR you could learn how to change the pressure on your Elite yourself. And increase the pressure by 1-2 cm for a week or two and see what the data looks like. If the AHI comes down to normal, you're good to go. If not, you increase the pressure setting by another 1-2 cm for another week or two. You will eventually find the right pressure, although it may take some time. And, of course, you'll be soundly criticized and whipped with a wet noodle every time the DME or sleep doc sees your data.

OR you could start lobbying the supplier (DME) to switch the machine out for the APAP you want, but, quite frankly, it won't easy to talk them into this without an order from your doc since they've already given you the false line that Medicare won't pay for an APAP.

OR you can try some combination of the above choices.

(06-06-2014 08:59 PM)jcarerra Wrote:  AHIs mostly in 10-12 range, remember one 7.x one 2.x.
I don't like AHI because you can have 6-7 hours of good data but 1-2 hours of near death and still have an acceptable AHI. It is an average that includes the "no problem" periods, which skews the number.
Yes, there are all kinds of things that "AHI" by itself tends to ignore. But docs are not in the habit of looking at subtleties. They want something that is relatively straightforward to measure, and AHI is what they've settled on.

Quote:I understand the quibble over the acronym--I think most people call ANY "give you air while you sleep" machine a CPAP, whether it varies the level or not. Even the ones that vary the level seldom lower the pressure to zero, therefore technically they are indeed correctly called CONTINUOUS---there is continuous pressure (as opposed to Constant Level). I don't get hung up over that.,
You are splitting a hair here that the medical community does not split for historical reasons.

The name CPAP = continuous positive air pressure was coined in the early days of treating OSA by something other than "do a trach on the patient if the OSA was a clear and immediate threat to the patient's life" and "ignore it if the OSA wasn't clearly an immediate threat to the patient's life". (And before CPAP, OSA was "ignored" for most patients; the risks+probems vs. benefits of a trach were simply too great to do them routinely on OSA patients.)

Back then no-one was even thinking about trying to design a machine that would automatically adjust during the night. The idea was (and largely remains): Find a (fixed) positive air pressure that keeps the patient's airway from collapsing when they are in REM supine sleep and have them use that pressure all night long, every single night. The "continuous" part of CPAP was that the patient had to have the (fixed) positive air pressure delivered continuously throughout the night.

And those early CPAP machines literally did NOTHING but blow air at a fixed pressure continuously all night long down the patient's upper airway. They didn't analyze the patient's breathing in any way, and hence they didn't record events that occurred during the night; heck the earliest ones didn't even record usage.

Once the technology advanced enough where it was possible for a CPAP machine to analyze the patient's breathing on a breath-by-breath basis, it was possible for companies to start marketing machines that recorded efficacy data, which includes both AHI data and leak data. And for the first time a doctor (or a patient) was able to determine whether the pressure arrived at through a manual titration study in a lab was indeed proving to be therapeutic in the patient's own home night after night.

And once it was possible to record efficacy data, someone eventually got the bright idea of designing a machine that could not only record the efficacy data, but respond to it. These machines are properly called Auto CPAPs---as in Automatically adjusting continuous positive air pressure machines. They've been renamed APAP for short.

Quote:I have not learned all the other abbreviations/acronyms for functions, data elements, etc. OSA? Quite the lingo here. Learning curve at hand and communication impacted until that is over.
Yes, there is a lot of abbreviations and acronyms. And it does take some time getting use to it all.

To start with: OSA stands for obstructive sleep apnea. It's the name of the primary condition that CPAP and APAP is designed to treat. OSA is characterized by the upper airway repeatedly collapsing or partially collapsing while the sufferer is asleep. When the airway collapses, the patient continues to try to breathe, but no air can get into the lungs. This can trigger an O2 desaturation in the blood or a mini-arousal or both. During the mini-arousal, the patient arouses just enough to consciously force the airway to open back up so normal breathing can resume. When the airway is collapsed for at least 10 seconds, it's called an obstructive apnea or an OA for short. A partial collapse of the airway leads to enough of a reduction in the amount of air getting into the lungs to either cause an O2 desat or a mini-arousal or both. Like an apnea, eventually the person arouses just enough to consciously force the airway to open up fully so that normal breathing resumes. When the partial collapse of the airway and reduced airflow lasts for at least 10 seconds, it's called a hypopnea or an H for short.

You might find some of the entries on my blog Adventures in HoseHead Land useful. In particular, it may help you to read through Understanding the data in your sleep test report as a starting place. I do a pretty thorough job of explaining a lot of the various acronyms that you run into on this board.
06-07-2014 03:26 AM
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jcarerra Offline

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Post: #10
RE: ResMed S9 Elite -- MANY apnea events still
Excellent post... Thanks.

I agree with your discussion of the terminology. In some sense, it doesn't matter, but in another, it is important for there to be common definitions so that correct communication occurs. I think the Auto CPAP is quite accurate and descriptive, but rarely used. The shortened version, APAP, is also accurate though not as clear to people who don't know it yet. CPAP now has become an aberration; if interpreted PURELY, it does not include APAPs (or whatever other variants of these there are...BiPAPs?? whatever that is). But many now are using the term CPAP to include ALL air-delivery machines, while others restrict it to only the historical fixed-level machines. So, it is THAT acronym--CPAP--that is now ill-defined, except to those people who have decided they know EXACTLY what it means! Smile

To my situation...
last night, I turned off the EPR? (acronym deficiency again) --the thing that reduced pressure on exhale. AND, I upped the pressure from 12 to 14.

My thinking on the EPR is that, even though I had it set to 'fast,' that pressure did not return to high level until the machine detected start of an inhale. But if you were 'apnea-ing' (especially a central), that signal would not even exist--and you would not get the pressure rise. I am thus running a machine essentially identical to those of decades ago, except that it collects data.

RESULT: AHI of 0.6--much better. I have not looked at the details yet.

I have a question: what is the contraindication for using pressures higher than "needed?" In other words, if 12 would mostly solve your issues, what would be the problem (danger?) of running at 14? <<<Should this be a separate topic for the forum?
(This post was last modified: 06-07-2014 10:14 AM by jcarerra.)
06-07-2014 10:09 AM
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