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ResMed S9 Elite -- MANY apnea events still
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robysue Offline
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Post: #31
RE: ResMed S9 Elite -- MANY apnea events still
(06-09-2014 03:14 PM)jcarerra Wrote:  I just went to my Primary Care doc's office today and picked up the sleep study and titration study reports. The latter says, " The patient will benefit from CPAP at 12cm...with heated humidifier."
...
I absolutely believe I need autoset--to get enough pressure during the clusters...and don't really understand the logic for anybody that says you need XXXX cm during events, so we will give it to you all night! huh? How is that sensible!
Bummer about the doc not willing to advocate for an APAP.

However, I do want to try to explain the logic behind the preference many doctors have for prescribing CPAP rather than APAP. It's important to understand that not all of the reasons that docs prefer prescribing CPAP to APAP boil down to some version of "super inflated ego" or "ignorant incompetence". Some of their logic does make sense to me, and some, quite frankly, does not. Regardless, here are some of the reasons that docs tend to prescribe CPAP at n cm rather than APAP with a range:

Many docs are simply not very aware of the wide choices in equipment that are out there.
This is particularly true of primary care physicians. They know CPAPs exist, but they really don't know that much about them. And hence they take the lab's recommendation and they write the script in the obvious way. Keep in mind that the average PCP has received very little formal training in sleep medicine, let alone CPAP management. And unless a very large number of his/her patients are relying on the PCP for CPAP follow up, a typical PCP has little reason to learn very much about CPAP therapy and is likely to simply defer to the specialist who wrote the sleep study summary.


Many of the docs who ARE knowledgeable about APAPs don't trust the APAP algorithms all that much--Part I.
Many of these docs are sleep docs. Why they distrust the APAP algorithms is a complex issue and it's not all about over-blown egos. Sometimes the distrust is long standing---the early Auto algorithms really did have some pretty severe problems and limitations.

There's a discussion on another board right now about the limitations of the S9 Escape Auto's auto algorithm vis a vis the newer S9 AutoSet's Auto algorithm. The Escape Auto's auto algorithm is the old S8 AutoSet's auto algorithm, and among other things, that particular algorithm will NOT increase the pressure in response to any cluster of apneas and hypopneas that occur when the pressure setting is AT or ABOVE 10 cm. The older auto algorithm was designed with this limitation in order to prevent inappropriate pressure increases in the small number of OSA patients who develop problems with pressure induced centrals.

So historically speaking, the Auto algorithms have a mixed record in terms of providing appropriate pressure responses when clusters of apneas and hypopneas are detected.


Many of the docs who ARE knowledgeable about APAPs don't trust the APAP algorithms all that much--Part II.
The newer Auto algorithms by Resmed and PR claim to distinguish between central and obstructive apneas and respond appropriately. But both companies are not very forth coming with the particulars of the algorithms (they are proprietary after all) and much of the data to back up the claims that the machines work as promised were done by the companies in company labs OR done with moneys coming from the companies. Independently bench testing the algorithms is not easy, and the handful of studies that I've been able to locate do point out that the different auto algorithms respond in very different ways. And it's not at all clear how a doctor should use those differences to choose an APAP that is most likely to work for a particular patient.

At the root of the distrust of the Auto algorithms ability to correctly respond to sleep disturbed breathing events is a mistrust of the machine's ability to accurately record efficacy data in the first place. There's a general consensus that the efficacy data is useful as trending data---the long term summary data is seen as having real value in the clinical setting for identifying which patients are still having real problems with under treated OSA after several weeks or months on PAP therapy. And that allows the doc to then consider what things might be contributing to the long term clinical reasons the person is not responding as expected to PAP therapy.

But on a breath-by-breath analysis basis, the sleep docs tend to remain on the skeptical side of trusting the detailed data that the APAP uses to determine when to raise the pressure and how much to raise the pressure by.

Many of these docs will trust the leak data---it's easy to establish how that data is gathered and what it means. But the AHI data? Again, each company that makes a full efficacy data machine has their own proprietary algorithms for scoring the events. And those scoring criteria are NOT readily available, but they do indeed matter when it comes to interpreting the data recorded.

Apneas are pretty easy to score: The flow rate into the lungs drops below 10% of the "running baseline" for at least 10 seconds is the usual definition. But how is the "running baseline" computed? And how much does that matter? Turns out, it varies a lot from company to company and it DOES affect the scoring of some "apneas".

The definition of hypopnea varies even more from company to company. Some companies choose "airflow is below 50% of the running baseline" and others choose "airflow is below 60% (or 70%) of the running baseline". When Resmed redid their hypopnea detection algorithm between the S8 series and the S9 series, they apparently reduced the sensitivity of the machine to score Hs by changing the criteria for scoring a hyponpena. A lot of people (both patients and docs) suspected the S8 was (possibly drastically) over scoring Hs; there are now some people who fret about whether the S9's underscore Hs.

Classifying the apneas as central or obstructive is even more controversial. The companies that claim their efficacy data machines can do so use proprietary algorithms, and hence there is limited information about how those algorithms are designed available to people not employed by the companies. What is known about the algorithms is that they typically are trying to distinguish between OAs and CAs based on the patency of the airway. The problem with is that in a lab, a central apnea can be scored even if the airway is blocked. Effort to breath is the critical piece of data for distinguishing a central apnea from an obstructive apnea in the lab. And it is known that in a certain number of people, the airway can and does collapse after the start of the central apnea. And this kind of central apnea can easily be mis-scored as an OA (and trigger an inappropriate pressure increase) by the existing central apnea detection algorithms.

And since PAP machines have no EEG, there is no way (beyond patient self report) to know whether a patient was awake or asleep when any particular event or cluster of events occurred. It's particularly difficult to tease out "sleep-wake-junk" (SWJ) breathing from the efficacy data. SWJ is when a person is dozing in and out of sleep and so some of the breathing is sleep transitional breathing and some is wake breathing. Both sleep transition breathing and wake breathing are regularly (and incorrectly) scored as CAs, OAs, and Hs by today's top of the line efficacy data machines. And when an APAP inappropriately raises the pressure during SWJ, that can make it harder for the patient to establish sound sleep with a regular, even sleep breathing pattern.

In short: The limitations on the accuracy of the breath-by-breath data can lead an APAP to respond inappropriately under some not uncommon circumstances. For many patients, this inappropriate response is not likely to do any real damage. But for a small group of patients, the inappropriate responses by their home APAP may contribute pretty significantly to poor efficacy results and/or serious adjustment problems.

Editorial note: While I think the problems with the accuracy of the data are real AND that in some cases inappropriate response to clusters of mis-classified or mis-scored events do cause serious problems, I think the answer is switching an APAP into straight CPAP mode rather than simply refusing to allow the patient to have (and try) and APAP running in Auto mode.


Well constructed double blind studies have repeatedly shown that starting people out on APAP instead of CPAP does NOT increase overall compliance rates or the effectiveness of therapy.
It is true that many (not all) of these studies use the default 4-20cm range for the APAPs, and that may very well put the APAPs at a disadvantage. But, if you read the advertising aimed at docs and dmes at the time APAPs were first being developed, the manufacturers were pushing the idea that leaving the APAP range wide open for the long term settings was a reasonable idea.

Still the fact remains: The manufacturers have tried to sell the idea of increased compliance with APAPs to the DMEs and sleep docs, but the scientific data indicates no statistical difference in compliance between newbies set up with CPAPs vs. APAPs.

Editorial Note: Quality scientific studies have shown that quality patient education and support, including close follow up from both the DME and doc during the first three months does significantly increase long term compliance. Studies have shown that docs and DMEs that are proactive in addressing common newbie problems have much better patient compliance than docs and DMEs who simply tell the newbie to contact them if the newbie runs into any problems.


Anecdotal evidence indicates that some people's sleep is deeply disturbed by the constantly changing pressures of a APAP in auto range.
There really are folks who sleep more soundly in CPAP mode than in Auto mode. And for a newbie, there's enough other stuff to get used to, so why add into that potent mix, the potential that changing pressures all night long will prove to be very disturbing to the new PAPer's sleep?

Editorial comment: Since APAPs can be set to CPAP mode, I personally do NOT think this is a reason to start people off with a straight CPAP machine rather than an APAP machine. If I had my way, people would start with an APAP set to CPAP mode and be switched to APAP either at the patient's request or when the patient starts having difficulties.

Conclusion
In conclusion, it's not merely a matter of some combination of inflated egos, laziness, incompetence, or ignorance that leads some sleep docs to strongly prefer prescribing CPAP at 12 cm over APAP at 9-14 cm.

But the thing is, setting a patient up with an APAP running in CPAP mode gives you more flexibility should things change in the future or should the patient run into problems. Smart DMEs know this and simply sell the patient an APAP set to CPAP mode when the patient comes in with a script that says CPAP at 12 cm. If the patient starts having problems and the doc decides to do a temporary auto-titration for a week or too to get some evidence in support of what an appropriate pressure might be, the DME doesn't have to set up a loaner machine, which they then have to take back and sterilize for the next person they lend it to. All the DME has to do is change the person's settings on his/her machine and send the patient on their way. And there's no more dealing with paperwork to explain a two week hole in the compliance data when talking to the insurance company.

In other words, the DMEs are as much (or more) to blame than the docs are when it comes to setting patients up with CPAPs instead of APAPs.
06-10-2014 12:59 PM
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Post: #32
RE: ResMed S9 Elite -- MANY apnea events still
(06-10-2014 12:59 PM)robysue Wrote:  Editorial comment: Since APAPs can be set to CPAP mode, I personally do NOT think this is a reason to start people off with a straight CPAP machine rather than an APAP machine. If I had my way, people would start with an APAP set to CPAP mode and be switched to APAP either at the patient's request or when the patient starts having difficulties.

I love this comment, and personally agree 100% with it.

Keep it as simple as possible in the beginning, and then change as desired/needed. Best of both worlds.

There is another current thread right now where a person can't sleep with her machine in 'auto' mode (a newer user), even with the ramp set at max.

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

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06-10-2014 01:23 PM
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Post: #33
RE: ResMed S9 Elite -- MANY apnea events still
These are ever-so-interesting responses. I love all the insight.
In my particular case, I have no ides how the decision was made. The statement I previously reported was in my titration report to my PCP. The the DME company brings the S9 Elite CPAP,

Further, I have no idea what the process is, or even if there is one, to examine "how it is working" and make changes--different settings or switch to an APAP, which seems to be ruled out by the current recommendation of the sleep study doctor to my PCP.

I may have had unrealistic expectations, but I knew I had a problem, the sleep study confirmed it, and the installed equipment is not (fully?) correcting it. And other than self experimentation (which I have already done by raising pressure from 12 to 14 a few days ago (events continue), I don't know where to go from here.
06-10-2014 02:10 PM
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Post: #34
RE: ResMed S9 Elite -- MANY apnea events still
The "bean counters" that run DME's aren't very good at distinguising short term costs from long term costs. They say the Autoset costs more so they use the Escape. But having to do one "2 week trial" eats up all the cost savings of using the Escape. If you do it more than once in the machines lifetime, you are now losing money by using the Escape. Then figure in the lost sales as providers that want the data will use a different DME.

An Autoset with built in wireless would be my ideal choice of CPAP machine to use. Good for the patient, the doctor and the DME (if they are looking at the big picture).
06-10-2014 02:15 PM
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robysue Offline
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Post: #35
RE: ResMed S9 Elite -- MANY apnea events still
(06-10-2014 10:30 AM)jcarerra Wrote:  It has dawned on me that I do not really know what my expectations should be for "successful" therapy.
The usual "definition" of "successful CPAP therapy" is a combination of two things: Successful CPAP therapy means there is:
    (1) A real and long term reduction in the number of sleep disturbed breathing episodes, along with all the physical reactions associated with the sleep disturbed breathing, and

    (2) the patient has an increased quality of life in terms of excess sleepiness, daytime fatigue, nocturnia, etc.
In other words you're feeling better and the data looks good.

Quote:But I don't know if that is right.
Is it unreasonable of me to expect there to be NO clusters?
It depends on what's causing the clusters. If they're REM related or supine sleep related, then finding the appropriate pressure should make them smaller and much more rarer, but you may still have a bad night from time to time. If they're sleep-wake-junk clusters caused by a long period of being "not quite asleep" and the machine mis-scoring sleep transition and wake breathing as sleep disturbed breathing events, then the clusters probably won't go away until the long periods of being "not quite asleep" go away.

Quote:Is having a scattered few events generally accepted as OK?
Yes. Even normal people without any sleep apnea problems at all will have the occasional apnea. From a medical point of view, the idea is to get to where there are fewer than 5 events per hour on average. Since you've already mentioned that this definition bugs you (legitimately) because it does not take into account really nasty clusters, you can interpret the clinical AHI < 5 as follows: It's reasonable to aim for getting to a place where you seldom ever see more than a few events in any one hour period.

But keep in mind that sleep does change from night to night. And once you do figure out your optimal pressure setting (on a CPAP) or optimal range (on an APAP) you will still likely have the occasional really bad night. On another forum, one of the well respected senior members refers to those rare really bad nights as a visit from the aliens.

Quote:Should I be looking to correct something in addition to the clusters?
There's a lot more to getting a good night's sleep than just the numbers. So pay attention to things the PAP can't tell you about as well:
  • How long does it take you to get to sleep?
  • How is the overall sleep hygiene?
  • How sound do you think you are sleeping? Any wakes or restlessness during the night that you remember?

Quote:For example, looking at last night's data (atch), my reaction is that I want that big cluster to not be there...but occasional ones not clumped together would be OK with me. I mean, I am on a machine...wasn't it supposed to eliminate this stuff? Isn't that why I have it?
The machine is never going to be PERFECT and even a person without sleep disordered breathing has the occasional obstructive apnea or hypopnea when they are sleeping. Hence it is unreasonable to expect that your AHI will be a perfect 0.0 night after night.

That said, the cluster in the data you attached is a potential concern. But the first question that has to be asked is: Where you soundly asleep during that hour long cluster? Or were you restless and dozing transitioning between Stage 1 sleep and wake?

If you were dozing and restless, these may all be false events, and the "sleep problem" is figuring out why you were semi awake and dozing for so long. Fix that and the cluster goes away.

If you were sound asleep, then the breathing pattern is likely sleep disordered breathing, and your pressure was probably not high enough during that hour. And the questions become:
    1) What triggered the cluster in the first place?
    2) Why did the cluster last so long?
The short answer to both questions is: We don't know.

But we can speculate. The three usual suspects for this kind of a cluster are: REM-related cluster; Supine sleep related cluster; or Sleep-Wake-Junk cluster.

The timing of the start of the cluster is not quite right for REM, since it starts about 2 to 2.5 hours after you turned the machine on. That's very late for the first REM cycle, and a bit early for the second REM cycle. Moreover, most REM cycles in the first half of the night don't usually last a full hour. And it looks like this cluster lasts about that long. So if the cluster started in REM, then why did it keep on going past the end of the REM cycle?

It could be you were sleeping on your back. But here's no way to tell that from the data. If your OSA is documented as being much worse in supine sleep, then focusing on figuring out a way to encourage yourself to stay off your back might be reasonable. Or trying to figure out how much pressure you actually need when you're on your back. One potential argument for an APAP set in an auto range is very different pressure needs between supine and non-supine sleep.

As for trying to tease out whether supine sleeping is the issue here, that's tough. If you have a way of video taping yourself for the entire sleep period, you might be able to determine whether the clusters are supine sleep related. If you're willing to risk a really bad night, you could intentionally fall asleep on your back for a night (or two) and make a note of whether you wake up on your back or in another position.

And then there's also the possibility that the cluster is SWJ breathing that's being mis-scored as apneas and hypopneas. But it's hard to establish for sure whether this is the problem without an EEG attached to your head. However one thing that might be able to point to a potential SWJ explanation of the clusters would be data from an accelerometer that infers "sleep state" from how much you are moving around in bed. The FitBit bracelet is a device that does this, albeit it may be more expensive than you want to invest. A less accurate, but far cheaper alternative would be any one of a number of smart phone Apps that claim to trace sleep/wake cycles. I've got something called SleepBot on my Android phone. And while I look at the SleepBot data with large grain of salt, I do think that it can track my most restless periods of moving around in bed with a decent amount of accuracy. So if you've got a smart phone, it may be worth trying to use something like SleepBot to see if the clusters of events are occurring when there's a lot of movement being done (which points to SWJ) or whether those event clusters are occurring when there's no movement at all being detected (which could point to a REM related cluster)

And then there's a THIRD big question that needs to be asked:
    3) Would an increase in pressure delivered by an APAP have managed to allow the breathing to stabilize?
The short answer is: We don't know.

If the events are SWJ, then increasing the pressure might not have done any good at all, and the pressure would have continued to increase until it hit the max pressure setting. And under really bad circumstances the sharp increase in pressure may actually even prolong the cluster.

If the events are real sleep disordered breathing, however, AND if they're correctly scored as OAs, then there's a pretty good chance the breathing would have stabilized after a pressure increase. But there's also a small chance that the breathing would not have stabilized, and the pressure would have continued to increase as events continued to be scored, and the breathing would have remained unstable. For most people, the chances of a pressure increase leading to worse breathing is not very great, but it is there and it is something you need to be aware of when you are dial winging your pressure settings. You don't want to get trapped in a cycle of constantly increasing the pressure settings over and over because you're still seeing an event cluster every night. At a certain point, if increasing pressures has not manage to reduce the number and length of the events, its reasonable to start thinking that something else might be involved.

I'm not saying you've reached this point (yet), but I am pointing out that you don't want to just keep increasing the pressure every time you see a nasty cluster. But it is reasonable to think about raising the pressure settings if you are seeing this kind of cluster on many nights.

(06-10-2014 10:56 AM)Bama Rambler Wrote:  One thing I notice is that when that cluster was occurring you were having a bunch of large leaks. Once your leaks get above 24lpm your therapy goes out the window because the machine can't maintain adequate pressure to keep the airway open. I suspect that if you fix whatever is causing those leaks you'll see the clusters go down.
The leaks during the nasty cluster spike above 24 L/min a grand total of 3 times, the longest of which might be a 5 minute large leak. The rest of the time during the cluster the leaks are below the Red Line, and for the much of the cluster the leaks are well below 24 L/min.

I don't think the leaks are playing much of a factor in what's keeping this cluster going on for an hour. Or rather: I dont' think the leaks are large enough or long enough to lead to ineffective therapy triggering the cluster. But it is possible that the leaks were large enough to cause a lot of restlessness and moving around. Or it's possible that restlesness and moving around caused the leaks. In either case, restlessness and moving around indicates that we need to consider whether jcarerra is really soundly asleep or not during this period.

jcarerra Wrote:I am thinking there is a possibility that whatever is happening, which includes serious snoring and very strange breathing by the way, is being misallocated by the sensors/algorithm as leak. Everything goes crazy during that time: events, leak, flow limitation, flow, snore index, minute ventilation (what is that by the way?)
Not sure what you mean by "everything goes crazy during that time". Yes, the events are coming fast and furious. And the flow limitations are crazy. But the upticks in the other graphs are slight uptick rather than "going crazy" upticks.

The snore graph hardly represents serious snoring. It's only 1/4 of the way up the snore scale. This soft snoring or mild-to-moderate snoring. If it was really serious snoring, the peak in the snoring graph would be above the 1/2 mark on the vertical axis.

Minute ventilation is the total amount of air inhaled in a one minute period (if the breathing pattern continues for a full minute without change). The minute ventilation graph is showing some activity, but given the large number of OAs being scored, that activity is not unusually large by any means. Given the y-axis scale on that minute ventilation graph, it's difficult to actually see just how much the MV is bouncing around.

Quote:I am thinking there is a possibility that whatever is happening, which includes serious snoring and very strange breathing by the way, is being misallocated by the sensors/algorithm as leak
There is indeed a possibility of a "very strange breathing" pattern, but at this level of magnification there's no way to tell for sure. If there is a "very strange breathing" pattern in the data, however, would only be misallocated to "leak" if the breathing pattern were triggering a leak. (If you were mouth breathing in a nasal mask for example).

More likely a "very strange breathing pattern" might consist of a breathing pattern that has the events mis-scored.

One possibility is SWJ. Wake breathing frequently looks weird compared to sleep breathing. And sleep transition breathing looks weird compared to sleep breathing. Hence the breathing during a SWJ period can look like a "very strange breathing pattern" and under the right circumstances SWJ breathing can trigger a lot of false events to be scored.

Another (less common) possibility is that your sleep breathing became unstable due to problems with the CO2 levels. In other words, the problem may be that many of the apneas that were scored as OAs should have been scored as CAs.

There's no way to tell what might be going on at this magification.

Any chance you could zoom in on just the hour long cluster? And could you also zoom in at a couple of the really nasty spots in the cluster close enough to see the individual breaths? In other words, can you show us what some 5 minutes intervals in that nasty cluster look like?
(This post was last modified: 06-10-2014 02:29 PM by robysue.)
06-10-2014 02:24 PM
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robysue Offline
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Post: #36
RE: ResMed S9 Elite -- MANY apnea events still
(06-10-2014 02:15 PM)jaycee Wrote:  The "bean counters" that run DME's aren't very good at distinguising short term costs from long term costs. They say the Autoset costs more so they use the Escape. But having to do one "2 week trial" eats up all the cost savings of using the Escape. If you do it more than once in the machines lifetime, you are now losing money by using the Escape. Then figure in the lost sales as providers that want the data will use a different DME.
This is why I tend to assign a fair amount of the "blame" to the DMEs. The DMEs are simply too short sighted and both the patients and the DMEs' long term financial line suffer for it.

If the DMEs would set folks up with APAPs set in CPAP mode to begin with, they would have far few machines to swap out and far happier customers. And a PAPer who makes it to full compliance and likes the DME needs less and less support over the long run and continues to generate revenue for years to come.

A PAPer given a brick and who fails to make it to full compliance does not.

An Autoset with built in wireless would be my ideal choice of CPAP machine to use. Good for the patient, the doctor and the DME (if they are looking at the big picture).
[/quote]
06-10-2014 02:35 PM
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Peter_C Offline

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Post: #37
RE: ResMed S9 Elite -- MANY apnea events still
robysue - Just want to give you (again) a Gold Star for effort and knowledge.

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

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06-10-2014 02:47 PM
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Post: #38
RE: ResMed S9 Elite -- MANY apnea events still
(06-10-2014 02:35 PM)robysue Wrote:  If the DMEs would set folks up with APAPs set in CPAP mode to begin with, they would have far few machines to swap out and far happier customers. And a PAPer who makes it to full compliance and likes the DME needs less and less support over the long run and continues to generate revenue for years to come.

A PAPer given a brick and who fails to make it to full compliance does not.

I agree. Unfortunately it does not say "Jaycee" on the sign out front of the DME I work at. I work under their rules. I make suggestions, but unfortunately they don't listen to "big picture" advice.

So I do the best I can with what they give me to work with.
06-10-2014 02:47 PM
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Post: #39
RE: ResMed S9 Elite -- MANY apnea events still
(06-10-2014 02:10 PM)jcarerra Wrote:  These are ever-so-interesting responses. I love all the insight.
In my particular case, I have no ides how the decision was made. The statement I previously reported was in my titration report to my PCP. The the DME company brings the S9 Elite CPAP,
The titration study is (almost) always going to report a single suggested pressure if the tech found a pressure that "worked" under the AASM guidelines for manual titration. (The AASM guidelines for manual titration are available on-line at http://www.aasmnet.org/Resources/clinicalguidelines/040210.pdf for those who are interested in them.)

So my guess is the tech found a pressure that "worked" according to the guidelines, and sent that information along with the sleep study data to the sleep doc supervising his/her work. And the sleep doc looked at the data long enough to make sure there are no obvious problems and signed the report that is sent to your PCP. And your PCP looked at the report and wrote the script for CPAP at 12 cm and faxed it to the DME.

Your DME was a (semi) responsible DME that understands the value of having efficacy data even when the prescribing doc doesn't specify it on the script. They probably set all or almost all of their new patients up with an S9 Elite when the script says nothing more than "CPAP at n cm." In this sense you got lucky: The S9 Elite records efficacy data and the more commonly distributed S9 Escape does not.

Quote:Further, I have no idea what the process is, or even if there is one, to examine "how it is working" and make changes--different settings or switch to an APAP, which seems to be ruled out by the current recommendation of the sleep study doctor to my PCP.
Since you have not actually been seen by a sleep doc, this is how the long term game is likely to play out:

At each annual physical with your PCP, your doc will ask whether you are continuing to use the machine.

If you say, YES you are using your machine, your doc will ask one follow-up question: And how are you feeling as far as the sleep is concerned?
  • If you say "Fine" or some other response that indicates you seem to be doing ok, nothing more will be said and your PCP won't look at the data.
  • If you say something that clearly indicates thatdon't feel as though your sleep is very good in spite of using the machine, your sleep doc will probably ask some additional questions. Depending on your answers and your insurance or HMO's rules about referring patients to specialists, the doc will likely do one of several things:
    • Decide to prescribe something himself to see if it works. If it sounds as though you are complaining of insomnia, he may just write a script for Ambien and be done with it for example.
    • Decide to send you back to the sleep lab to check the pressure setting for your machine. Or, perhaps, if your PCP is particularly knowledgeable about CPAPs, he might either send the DME a script requesting a two week Auto titration on an APAP or he might simply send a script over to the DME to increase your pressure by 1 or 2 cm. The doc will probably not base this decision on looking at the data your machine recorded unless you bring him a hard copy and point out that you think your data is not as good as it should be.
    • Refer you to a sleep specialist who actually sees and treats patients. At which point the records of your sleep studies will be faxed to sleep doc for his use. At the appointment with the sleep doc, the doc may be willing to look at your machine's data. He may even want to look at more than just compliance data. What the sleep doc will recommend will depend on just how bad your therapy numbers seem to be and (equally important) just how bad you're feeling concerning the quality of your sleep.

On the other hand, if you tell your PCP that you are NOT using the machine, you'll probably get a wet-noodle whipping about how you really need to start using it again. And the PCP will probably start asking you about the quality of your sleep and whether you're using the machine on each subsequent visit regardless of what the purpose of the visit is. And if at some point you develop a co-morbidity of OSA or if you start complaining loudly about daytime sleepiness or exhaustion or bad sleep, the PCP will send you back to the sleep lab to start all over ...

Quote:I may have had unrealistic expectations, but I knew I had a problem, the sleep study confirmed it, and the installed equipment is not (fully?) correcting it. And other than self experimentation (which I have already done by raising pressure from 12 to 14 a few days ago (events continue), I don't know where to go from here.
How long have you been using your equipment?

CPAP is a process and it can take time for the AHI to fully resolve down to where it's going to stay long term.
06-10-2014 03:02 PM
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jcarerra Offline

Advisory Members

Posts: 284
Joined: Jun 2014

Machine: ResMed S9 Adapt SV
Mask Type: Full face mask
Mask Make & Model: Quattro
Humidifier: H5i
CPAP Pressure: min/max EPAP 9/15 min/max PS 4
CPAP Software: ResScan

Other Comments:

Sex: Male
Location: Florida

Post: #40
RE: ResMed S9 Elite -- MANY apnea events still
This is not a thorough answer to the great inputs
(thanks ever so much to all)
...but quick answers to several things I remember from your remarks.

Have had the machine 11 days. Guess I am rushing things expecting solutions this quick, huh? Smile

--General pattern over 11 days = one or two clusters every night except one

My subjective assessment of changes since the machine:
- Before machine, I was conscious of many wakeups during the night. In my mind, they were to roll from left/right side to right/left. Occasionally I would go on back until sandman presence felt, then move to a side position usually.
-- After machine, I am definitely UNAWARE of so many rollovers--only one or two, more often remembering none.
--HOWEVER, I do NOT feel much more rested during the day...minimally at best.

My S9 Elite DOES have a cell transmitter gadget attached to the back that blinks a blue light around the base of the antenna.
A specific question here: does that imply that my data is being sent to someone for efficacy analysis, or only for compliance certification?

It just seems immensely logical that a check of "is the therapy working" would be part of the process. (Aren't they concerned about providing an expensive machine that might be accomplishing little?) I would envision that as taking the SD card to "somebody" who would copy the data, and a few days later give me analysis results and changes to make. Guess not. But I am repeating myself here.

Am I correct that I should cool it for a longer period of data collection?
(Although it appears I am the only one who will assess it.)

Oh, I changed the scale on Minute ventilation in Options, but it does not 'take" no matter what.
I will work on creating the expanded charts as requested.
(This post was last modified: 06-10-2014 03:58 PM by jcarerra.)
06-10-2014 03:49 PM
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