ResMed S9 Elite -- MANY apnea events still

[zonk]

Do you think a cluster is most likely in on back position?
Did the last image tell you anything?

Cannot tell without someone watching over you during the night or having a camera recording while you sleep

Did your sleep study said something about clusters in supine position or during REM stages

[jcarerra]

Sleep study told me NOTHING--except verbally from tech that I had one central of 62 seconds. I don't think they were supposed to tell me anything.

Then results went to their analyzing doc who wrote a report that went to my Primary Care doc, who ordered the CPAP, and the Elite was delivered to my house and set up.

Guess I should try to get a copy of the report from my Primary Care.

[robysue]

I do sleep mostly on my sides, but can't guarantee am never on back when I am too asleep to know. Before CPAP, I was awake a lot changing positions; now much less. I am CONSCIOUSLY on back only when cannot drop off in a side position, then being on back seems to bring on the sleep feeling, but then something inside me says to go to a side position before the conk-out. Of course, if I am really asleep, I don't know what I might be doing.

Do you think a cluster is most likely in on back position?
Did the last image tell you anything?

My guess is that both clusters are REM-related. The first starts about 90 minutes after you went to bed and the second one starts about 4.5 hours after the first one ends. REM cycles typically occur every 90 minutes or so, so the timing is right for REM.

Of course that would also mean that the intermediate REM cycles weren't so problematic. It's not clear why some REM cycles trigger a lot of events and other REM cycles are well managed by the PAP.

It's also possible that both cycles are supine REM sleep. For many people, that's when their apnea is at its worst.

Guess I should try to get a copy of the report from my Primary Care.

Yes, you should request the full sleep study report including the summary graphs that show when you had events and what kind they were. The whole report will run somewhere between 3 and 7 pages.

And if you had a separate titration report, you should request that report as well.

[Peter_C]

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.

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.

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.

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.

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.

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.

The above is/was my complete story - starting 15yrs ago.

[jcarerra]

I will look at those links.

What is the exact full name of the ResMed VPAP machine, and how does it differ from the Autoset?

[robysue]

I will look at those links.

What is the exact full name of the ResMed VPAP machine, and how does it differ from the Autoset?

The Resmed S9 VPAP S is the standard fixed bi-level continuous positive air pressure machine (bi-PAP or bi-level CPAP for short) in the Resmed S9 line-up. It differs from the S9 Auto Set in the following ways:

1) It has no Auto algorithm.

2) It has two fixed pressure settings: The EPAP, which is the pressure delivered when you are exhaling and the IPAP, which is the pressure delivered when you are inhaling.

3) The pressure support (PS) is the difference between the IPAP and the EPAP. In other words:

• PS = IPAP - EPAP

When PS = 0, 1, 2, or 3, the S9 VPAP S behaves very much like an S9 Elite with EPR set to OFF, 1, 2, or 3 respectively. There is a very minor difference between the VPAP S and the Elite in how the two machines increase the pressure at the end of the exhalation. However on the VPAP S, the PS can be set higher than 3cm. In other words, a VPAP S can be set to deliver (much) more "pressure relief" at the beginning of the exhalation. Common VPAP S settings usually have the PS set to 4-6cm, but PS can be set even higher than 6 cm.

4) The maximum pressure setting is 25 cm rather than 20 cm.


The Resmed S9 VPAP Auto is standard auto adjusting bi-level continuous positive air pressure machine (auto bi-PAP or auto bi-level CPAP for short) in the Resmed S9 line-up. It is similar to the S9 VPAP S, except that the S9 VPAP Auto has an auto algorithm. In other words, the S9 VPAP Auto differs from the S9 AutoSet in the following ways:

1) It has three main therapeutic settings:

• min EPAP
  max IPAP
  PS

The maximum EPAP and minimum IPAP values are derived from the settings as follows:

• min IPAP = min EPAP + PS
  max EPAP = max IPAP - PS
  

2) The auto algorithm is very similar to the S9 AutoSet's algorithm: It responds to snoring, flow limitations, obstructive apneas and hypopneas by increasing both the EPAP and IPAP by the same amount. In other words, at all times, IPAP = EPAP + PS. Hence:

• EPAP ranges from min EPAP to max IPAP - PS
  IPAP ranges from min EPAP + PS to max IPAP
  IPAP - EPAP = PS at all times.

3) If PS = 0, 1, 2, or 3, the VPAP Auto behaves very much like an S9 Auto with EPR set to OFF, 1, 2, or 3 respectively. There is a very minor difference between the VPAP Auto and the AutoSet in how the two machines increase the pressure at the end of the exhalation. However on the VPAP Auto, the PS can be set higher than 3cm. In other words, a VPAP Auto can be set to deliver (much) more "pressure relief" at the beginning of the exhalation. Common VPAP Auto settings usually have the PS set to 4-6cm, but PS can be set even higher than 6 cm.

4) The maximum pressure setting is 25 cm rather than 20 cm.


Other things to be aware of:

1) Billing codes. The S9 VPAP S and the S9 VPAP Auto are billed under the same billing code; so if you have a generic prescription for a bi-level device you are legally able to buy either one of them. But the billing code for the VPAP S and VPAP Auto is NOT the same as the billing code for a plain old CPAP/APAP. In other words, if you have a script that reads, "CPAP at n cm" or "APAP with min pressure = m cm and max pressure = M cm", then you are NOT legally able to buy a VPAP S or VPAP Auto from a DME.

2) Bi-level tirations. Most docs will insist on a bi-level titration if they are going to switch a CPAPer in trouble to bi-level. During the titration, the tech will typically increase only the IPAP in response to hypopneas and flow limitations. The tech will increase EPAP or both EPAP and IPAP in response to obstructive apneas and snoring. Whether both EPAP and IPAP are increased depends on how far apart EPAP and IPAP are at the time the OAs and/or snoring occur.

3) Cost. The cost of a typical bi-level machine is typically about twice the cost of the APAP in the same brand and model line. Auto bi-levels are a bit more expensive than fixed bi-levels.

[jcarerra]

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." So, NOT authorized autoset or bi. Bummer.

My conclusions SO FAR are that the 12 was probably accurate for THAT NIGHT, but is insufficient for me in general. After delivery of the machine and getting set up to see my data, I saw that I was still having major event clusters. Raising it to 14 and stopping EPR has reduced them, but still very evident--so I am still examining data and cogitating on the results on a continuing basis.

"The system", however, seems far too clumsy for zeroing in on right settings for a patient. A single noght, and BOOM--there are your lifetime settings. The string of contract for patient> PCP> sleep company> sleep company's analyzing doctor does not allow for any kind of conversation nor for a feedback>correction process to occur. Can't wait for the reaction to my changing pressure on my own up to 14.

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!

[jcarerra]

It has dawned on me that I do not really know what my expectations should be for "successful" therapy. 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?

But I don't know if that is right.
Is it unreasonable of me to expect there to be NO clusters?
Is having a scattered few events generally accepted as OK?
Should I be looking to correct something in addition to the clusters?

[Bama Rambler]

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.

While you should be able to get rid of mot clusters, you shouldn't expect a completely event free night. A few events isn't a problem at all.

[jcarerra]

I noticed that too, but am completely baffled by it. Leaks seem perfectly OK except during that time--which makes no sense at all. Too, there was only a small bit of that whole period that was above 24lpm; the vast majority of the time it was much less, and events were still occurring.

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?)

But I have to also allow for the possibility that there was a leak, just for that period only, and which just happened to coincide with REM sleep, that allowed for events to not be corrected. That seems possible, but unlikely.