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Saw my sleep doc today...changes
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DeepBreathing Offline
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Post: #11
RE: Saw my sleep doc today...changes
10 L/min is OK. Resmed machines don't like leaks over 24 and you'll get a frowney face if you go over 24 for more than 30% of the night. Obviously the lower the better, and you can get quite low leak rates which still disturb your sleep (eg face farts or air blowing into your eyes). AHI of 0.7 is really good.

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10-09-2015 05:44 AM
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zonk Offline

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Post: #12
RE: Saw my sleep doc today...changes
(10-09-2015 03:56 AM)cate1898 Wrote:  So I don't understand. Is 10L/min bad? good?
Resmed machines report unintentional 95th percentile leak rate, means leak was at or below this number for 95% of the time
10 L/m is excellent results .... good job
You'll need set the period to 1 day and mask type to 'Nasal' as you're using nasal pillows.
As for headache, at times I wake up with a headache and notice one side of my nose completely blocked and not getting enough air from the other side, something to do with 'nasal cycle'. When that happen, I switch to full face mask
Your headache could be entirely for a different reason
10-09-2015 06:29 AM
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PaytonA Offline
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Post: #13
RE: Saw my sleep doc today...changes
(10-08-2015 04:04 PM)sonicboom Wrote:  Here is a post of mine from a recent thread on the topic of low v actual AHI and recent literature:

28RE: LOW AHI vs actual REAL quality sleep
In follow up to my post (#21 above) and all of the great comments that followed I thought I'd do a quick internet search (by no means intended to be exhaustive) on what research has been done on the question of the accuracy of APAP AHI scoring versus sleep study (PSG). I found two studies that seem to be on point.

Title:
Accuracy of Auto-Titrating CPAP to Estimate the Residual Apnea-Hypopnea Index in Patients
with Obstructive Sleep Apnea on Treatment with Auto-Titrating CPAP.
Authors:
Himanshu Desai M.D.1, Anil Patel M.D.2, Pinal Patel M.B.B.S.1, Brydon J.B. Grant M.D.1 and M. Jeffery Mador M.D.1, 3.


"Bland and Altman plots demonstrate that the difference between auto-CPAP AHI and PSG AHI was not uniform with auto-CPAP overestimating the AHI at lower values of AHI and underestimating the AHI at higher values of AHI." (My quotes added)

http://www.acsu.buffalo.edu/~grant/94.pdf

Quote from the linked abstract. "Bland and Altman analysis showed good agreement between auto CPAP AHI and PSG AHI.

(10-08-2015 04:04 PM)sonicboom Wrote:  The second study: (I have excerpted a few paragraphs. You should read the whole thing when you have time.)


Sleep Disorders
Volume 2013 (2013), Article ID 314589, 6 pages
http://dx.doi.org/10.1155/2013/314589
Research Article
Accuracy of Positive Airway Pressure Device—Measured Apneas and Hypopneas: Role in Treatment Followup
Carl Stepnowsky,1,2 Tania Zamora,1 Robert Barker,3 Lin Liu,4 and Kathleen Sarmiento2,3
1Health Services Research & Development Unit, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
2Department of Medicine, University of California, San Diego, CA 92037, USA
3Pulmonary Service, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
4Department of Family and Preventive Medicine, University of California, San Diego, CA 92037, USA

Received 30 April 2013; Revised 16 July 2013; Accepted 19 July 2013

Academic Editor: Giora Pillar

Copyright © 2013 Carl Stepnowsky et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Improved data transmission technologies have facilitated data collected from positive airway pressure (PAP) devices in the home environment. Although clinicians’ treatment decisions increasingly rely on autoscoring of respiratory events by the PAP device, few studies have specifically examined the accuracy of autoscored respiratory events in the home environment in ongoing PAP use. “PAP efficacy” studies were conducted in which participants wore PAP simultaneously with an Embletta sleep system (Embla, Inc., Broomfield, CO), which was directly connected to the ResMed AutoSet S8 (ResMed, Inc., San Diego, CA) via a specialized cable. Mean PAP-scored Apnea-Hypopnea Index (AHI) was 14.2 ± 11.8 (median: 11.7; range: 3.9–46.3) and mean manual-scored AHI was 9.4 ± 10.2 (median: 7.7; range: 1.2–39.3). Ratios between the mean indices were calculated. PAP-scored HI was 2.0 times higher than the manual-scored HI. PAP-scored AHI was 1.5 times higher than the manual-scored AHI, and PAP-scored AI was 1.04 of manual-scored AI. In this sample, PAP-scored HI was on average double the manual-scored HI. Given the importance of PAP efficacy data in tracking treatment progress, it is important to recognize the possible bias of PAP algorithms in overreporting hypopneas. The most likely cause of this discrepancy is the use of desaturations in manual hypopnea scoring.

……

http://www.hindawi.com/journals/sd/2013/314589/

What I think that I have taken away from reading these studies is that there is good agreement between the auto machines and manual scoring of apneas. There is a fair amount of discrepancy between the machine scored hypopneas and the manually scored hypopneas due to the oxygen desaturation portion of the definition of a hypopnea which the machine can not determine.

So if AHI contains few hypopneas, there is good agreement between machine scores and manual scoring. If there are a number of hypopneas then the machine tends to overestimate. This may explain why Resmed altered the requirements for scoring a hypopnea when they brought out the S9. As a result the agreement is probably closer now than it was during the study.

Best Regards,

PaytonA
10-09-2015 11:02 AM
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quip Offline

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Post: #14
RE: Saw my sleep doc today...changes
(10-08-2015 11:17 PM)big_dave Wrote:  
(10-08-2015 07:13 PM)PoolQ Wrote:  No idea what a mac does if anything.

A Mac makes a mess, adding three system folders and another system file. I'm not really sure what they do. They don't bother my DS-560, so I leave the write-protect tab alone.

I personally have been locking my SD card before I have been putting it into my iMac lately. The only problem with that is - I think once or twice I must of forgotten to unlock (my write protection tab) on my SD card because last night I was on my PAP machine for 5 hours and BOTH Sleepyhead & Sleep Mapper only picked up my nap at 2.3 hours. So, that would seem to indicate that if anyone of us fails to unlock our SD cards again BEFORE we stick them into our PAP machines, then the PAP machine won't be able to write the data on the SD card. Interesting.

Be the change that you wish to see in the world
10-09-2015 11:39 AM
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sonicboom Offline

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Post: #15
RE: Saw my sleep doc today...changes
Hi PaytonA:

After reading these studies I too came away with the feeling that the correlation between the machine and the manual scoring was close enough to be reliable for our purposes of titrating our own therapy - hence, it is why I posted it here for Cate to show her doctor to educate him that the literature supports giving her an APAP machine. happy pappin,

Coffee

Coffee
10-09-2015 11:47 AM
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cate1898 Offline

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Post: #16
RE: Saw my sleep doc today...changes
(10-09-2015 11:47 AM)sonicboom Wrote:  Hi PaytonA:

After reading these studies I too came away with the feeling that the correlation between the machine and the manual scoring was close enough to be reliable for our purposes of titrating our own therapy - hence, it is why I posted it here for Cate to show her doctor to educate him that the literature supports giving her an APAP machine. happy pappin,

Coffee

I forgot to comment on your very detailed and thought provoking post and for that I apologize. Although a bit difficult to follow I got the gist that the auto machines are noting more events and the manual lab diagnostics/techs do not record enough or perhaps some events are not caught by lab equipment. Or at least that was what I thought.

I sort of felt that it backed up my thoughts that after a sleep lab was done to diagnose sleep apnea, that perhaps a sleep technician supervised auto CPAP machine titration in a sleep lab should be the next best step. But I'm not sure I'm understanding like those knowledgeable people on this forum like yourself.

Anyway, I can certainly print your post off and take it with me in November when I go back and see the sleep doc, but I'm pretty sure based on my 3 visits with him so far that he will not be terribly receptive to this and may see it as a challenge. I will have to be very delicate in what I say when I once again broach this subject with him.

I still believe he is far, far from being technologically minded. He just told me he'd have a look at my data when I next returned to see him, and didn't seem to comprehend what I'd said when I mentioned that my S9 Escape was only capable of providing him with compliance hours. I was rather surprised by this.

I had to explain to him that I had done my research and that the CPAP machine I had been loaned was incapable of providing him with the data he required and that I needed the DME to change the machine for a data capable one. It was apparent to me that he had no idea about the different CPAP machines at all.

APNEABOARD - A great place to be if you're a hosehead!! Rolleyes

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10-09-2015 02:15 PM
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TyroneShoes Offline

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Post: #17
RE: Saw my sleep doc today...changes
The process for PSG and APAP are different. The APAP does not have any of the sensors that the PSG has, but the PSG does not have the sensor that the APAP uses. All processes estimate by educated guessing, and neither can actually identify any sleep event directly. So there is always guesswork going on here, and therefore always inaccuracy.

How accurate does it need to be? Only accurate enough not to skew results that would hurt the diagnosis changing the prescription.

The APAP may be less accurate than the PSG, but it is just a matter of degree. Both are good tools, and both should be part of everyone's therapy.

Many in the industry, which is a profit center for many of these doctors, are threatened by the fact that the PSG is not the be-all anymore. If the studies show that the APAP is nearly as accurate, just really how important is the $3700 sleep study, which is 95% profit? Some docs react by being in denial; some react by circling the wagons and adopting bunker mentality. But neither of those mesh with the Hippocratic Oath in any way.

The data in my sleep study is based on about 2 hours of me being in great pain from the soft mattress, and being disoriented and very uncomfortable not sleeping in my own bed. Factors like this detract greatly from the information being all that empirical or thorough, or even all that helpful. On the other hand, in the last year alone I have 2800 hours of hard data from me being comfortable in my exact sleeping environment, from my APAP. And I used this data to fine tune and cut my AHI in half from where it was when following the doc's recommendations on pressure.

With that in mind, is the data from the APAP worse than the data from the PSG? Maybe its actually better, since there is so much of it (1400 times more than from the PSG) and since my sleep environment preserves the empirical nature of that data.

The reported inaccuracy? Claiming a slightly lower AHI when AHI is high is not an issue, because we already know it is too high and must be engineered to come down through therapy. Claiming a slightly higher AHI when AHI is low is also not an issue, because we have a low AHI already, and a slight increase in reporting it does not set off any alarm bells. So the inaccuracy is essentially meaningless.

Sleep disturbance events are not precise and identifiable; each is a matter of degree, and many times an "event" is actually a morphing of one kind of event and another. There is no black and white, only shades of grey. So accuracy is not ever going to be precise. Whether thinking I have $250,000 currently in my IRA is not really any less important than knowing it is actually $250,000.02; accuracy is often over-rated and distracting from what is really important anyway

And if you have 2800 hours of data like I do, you can peruse it at your leisure, and even parse it to the nth degree. Get out the microscope and look at it and interpret it as thoroughly as you want to. Using what you find to change your AHI from a 3 to a 1.5 is not an insignificant goal, because it means being strangled in your sleep 12 fewer times every night. And that is something I could not have accomplished with a CPAP, which also would likely yield an even higher AHI because it does absolutely nothing to treat or prevent SA other than blow constantly like a hair dryer. An APAP is essential for this sort of fine-tuning or augmentation of the therapy, whether the doc likes it or not.

The two hours of data from my PSG were probably looked at for about 45 seconds, by a doctor in the system who is basically forced to see patients on a conveyor belt; they are always trying to beat the clock, so they do the bare minimum. Because that is the system we have. But being able to breathe while asleep is quite literally a matter of life and death, and a matter of life extension for those relieved of the suffering. The advantages of an APAP over a CPAP measured in how much longer one will preserve my health more than the other, could mean more days, weeks, months, and years. Even decades. How much is even just one more day on earth worth compared to the difference in the costs of these technologies?

So a sleep doc resisting APAP is questionable at best, and probably never really in the patient's best interests as much as it might be in the interests of supporting the status quo before this disrupter technology of APAP came along. But it is nearly 2016, so they need to get with the program.

I think manufacturers should abandon CPAP altogether, since there is nothing that a CPAP can do that an APAP can't do, and plenty that an APAP can do that a CPAP can't even pretend to do.
(This post was last modified: 10-09-2015 05:31 PM by TyroneShoes.)
10-09-2015 05:22 PM
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ramblingasian Offline

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Post: #18
RE: Saw my sleep doc today...changes
(10-09-2015 05:22 PM)TyroneShoes Wrote:  The process for PSG and APAP are different. The APAP does not have any of the sensors that the PSG has, but the PSG does not have the sensor that the APAP uses. All processes estimate by educated guessing, and neither can actually identify any sleep event directly. So there is always guesswork going on here, and therefore always inaccuracy.

How accurate does it need to be? Only accurate enough not to skew results that would hurt the diagnosis changing the prescription.

The APAP may be less accurate than the PSG, but it is just a matter of degree. Both are good tools, and both should be part of everyone's therapy.

Many in the industry, which is a profit center for many of these doctors, are threatened by the fact that the PSG is not the be-all anymore. If the studies show that the APAP is nearly as accurate, just really how important is the $3700 sleep study, which is 95% profit? Some docs react by being in denial; some react by circling the wagons and adopting bunker mentality. But neither of those mesh with the Hippocratic Oath in any way.

The data in my sleep study is based on about 2 hours of me being in great pain from the soft mattress, and being disoriented and very uncomfortable not sleeping in my own bed. Factors like this detract greatly from the information being all that empirical or thorough, or even all that helpful. On the other hand, in the last year alone I have 2800 hours of hard data from me being comfortable in my exact sleeping environment, from my APAP. And I used this data to fine tune and cut my AHI in half from where it was when following the doc's recommendations on pressure.

With that in mind, is the data from the APAP worse than the data from the PSG? Maybe its actually better, since there is so much of it (1400 times more than from the PSG) and since my sleep environment preserves the empirical nature of that data.

The reported inaccuracy? Claiming a slightly lower AHI when AHI is high is not an issue, because we already know it is too high and must be engineered to come down through therapy. Claiming a slightly higher AHI when AHI is low is also not an issue, because we have a low AHI already, and a slight increase in reporting it does not set off any alarm bells. So the inaccuracy is essentially meaningless.

Sleep disturbance events are not precise and identifiable; each is a matter of degree, and many times an "event" is actually a morphing of one kind of event and another. There is no black and white, only shades of grey. So accuracy is not ever going to be precise. Whether thinking I have $250,000 currently in my IRA is not really any less important than knowing it is actually $250,000.02; accuracy is often over-rated and distracting from what is really important anyway

And if you have 2800 hours of data like I do, you can peruse it at your leisure, and even parse it to the nth degree. Get out the microscope and look at it and interpret it as thoroughly as you want to. Using what you find to change your AHI from a 3 to a 1.5 is not an insignificant goal, because it means being strangled in your sleep 12 fewer times every night. And that is something I could not have accomplished with a CPAP, which also would likely yield an even higher AHI because it does absolutely nothing to treat or prevent SA other than blow constantly like a hair dryer. An APAP is essential for this sort of fine-tuning or augmentation of the therapy, whether the doc likes it or not.

The two hours of data from my PSG were probably looked at for about 45 seconds, by a doctor in the system who is basically forced to see patients on a conveyor belt; they are always trying to beat the clock, so they do the bare minimum. Because that is the system we have. But being able to breathe while asleep is quite literally a matter of life and death, and a matter of life extension for those relieved of the suffering. The advantages of an APAP over a CPAP measured in how much longer one will preserve my health more than the other, could mean more days, weeks, months, and years. Even decades. How much is even just one more day on earth worth compared to the difference in the costs of these technologies?

So a sleep doc resisting APAP is questionable at best, and probably never really in the patient's best interests as much as it might be in the interests of supporting the status quo before this disrupter technology of APAP came along. But it is nearly 2016, so they need to get with the program.

I think manufacturers should abandon CPAP altogether, since there is nothing that a CPAP can do that an APAP can't do, and plenty that an APAP can do that a CPAP can't even pretend to do.

Unfortunately in this case, the OP's doctor cannot just give her an APAP as she lives in Ontario, Canada where if she wants a machine at a lower subsidized cost there are restrictions set aside as to which machine is given to which patient.

I agree with you that APAPs should be the norm, but I want to make clear to those in Ontario that just because you read that APAP's are better, that your sleep doctor may have his/her hands tied in prescribing you a CPAP machine based on your diagnosis.

EDIT: You can still purchase an APAP on your own - the government just will not cover the cost, nor will most private insurance plans.
(This post was last modified: 10-09-2015 05:45 PM by ramblingasian.)
10-09-2015 05:37 PM
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eseedhouse Offline

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Post: #19
RE: Saw my sleep doc today...changes
(10-09-2015 05:22 PM)TyroneShoes Wrote:  The data in my sleep study is based on about 2 hours of me being in great pain from the soft mattress, and being disoriented and very uncomfortable not sleeping in my own bed. Factors like this detract greatly from the information being all that empirical or thorough, or even all that helpful. On the other hand, in the last year alone I have 2800 hours of hard data from me being comfortable in my exact sleeping environment, from my APAP.

This may be true, but a ton poor data is outweighed by a single night of good data. A properly done overnight sleep study is definitive.

Not that I don't use the data from my machine - indeed I study it carefully every morning. Still one must be careful in one's assumptions.

I also think the data provided from the machines is pretty good. But the medical profession must rely on replicated studies and they may not be in yet, so if that's true they won't have a basis to change their approach.

Ed Seedhouse
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I am neither a Doctor, nor any other kind of medical professional.

Actually you know, it is what it isn't.
10-09-2015 07:19 PM
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cate1898 Offline

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Post: #20
RE: Saw my sleep doc today...changes
(10-09-2015 05:22 PM)TyroneShoes Wrote:  The process for PSG and APAP are different. The APAP does not have any of the sensors that the PSG has, but the PSG does not have the sensor that the APAP uses. All processes estimate by educated guessing, and neither can actually identify any sleep event directly. So there is always guesswork going on here, and therefore always inaccuracy.

How accurate does it need to be? Only accurate enough not to skew results that would hurt the diagnosis changing the prescription.

The APAP may be less accurate than the PSG, but it is just a matter of degree. Both are good tools, and both should be part of everyone's therapy.

Many in the industry, which is a profit center for many of these doctors, are threatened by the fact that the PSG is not the be-all anymore. If the studies show that the APAP is nearly as accurate, just really how important is the $3700 sleep study, which is 95% profit? Some docs react by being in denial; some react by circling the wagons and adopting bunker mentality. But neither of those mesh with the Hippocratic Oath in any way.

The data in my sleep study is based on about 2 hours of me being in great pain from the soft mattress, and being disoriented and very uncomfortable not sleeping in my own bed. Factors like this detract greatly from the information being all that empirical or thorough, or even all that helpful. On the other hand, in the last year alone I have 2800 hours of hard data from me being comfortable in my exact sleeping environment, from my APAP. And I used this data to fine tune and cut my AHI in half from where it was when following the doc's recommendations on pressure.

With that in mind, is the data from the APAP worse than the data from the PSG? Maybe its actually better, since there is so much of it (1400 times more than from the PSG) and since my sleep environment preserves the empirical nature of that data.

The reported inaccuracy? Claiming a slightly lower AHI when AHI is high is not an issue, because we already know it is too high and must be engineered to come down through therapy. Claiming a slightly higher AHI when AHI is low is also not an issue, because we have a low AHI already, and a slight increase in reporting it does not set off any alarm bells. So the inaccuracy is essentially meaningless.

Sleep disturbance events are not precise and identifiable; each is a matter of degree, and many times an "event" is actually a morphing of one kind of event and another. There is no black and white, only shades of grey. So accuracy is not ever going to be precise. Whether thinking I have $250,000 currently in my IRA is not really any less important than knowing it is actually $250,000.02; accuracy is often over-rated and distracting from what is really important anyway

And if you have 2800 hours of data like I do, you can peruse it at your leisure, and even parse it to the nth degree. Get out the microscope and look at it and interpret it as thoroughly as you want to. Using what you find to change your AHI from a 3 to a 1.5 is not an insignificant goal, because it means being strangled in your sleep 12 fewer times every night. And that is something I could not have accomplished with a CPAP, which also would likely yield an even higher AHI because it does absolutely nothing to treat or prevent SA other than blow constantly like a hair dryer. An APAP is essential for this sort of fine-tuning or augmentation of the therapy, whether the doc likes it or not.

The two hours of data from my PSG were probably looked at for about 45 seconds, by a doctor in the system who is basically forced to see patients on a conveyor belt; they are always trying to beat the clock, so they do the bare minimum. Because that is the system we have. But being able to breathe while asleep is quite literally a matter of life and death, and a matter of life extension for those relieved of the suffering. The advantages of an APAP over a CPAP measured in how much longer one will preserve my health more than the other, could mean more days, weeks, months, and years. Even decades. How much is even just one more day on earth worth compared to the difference in the costs of these technologies?

So a sleep doc resisting APAP is questionable at best, and probably never really in the patient's best interests as much as it might be in the interests of supporting the status quo before this disrupter technology of APAP came along. But it is nearly 2016, so they need to get with the program.

I think manufacturers should abandon CPAP altogether, since there is nothing that a CPAP can do that an APAP can't do, and plenty that an APAP can do that a CPAP can't even pretend to do.

TyroneShoes that was a very interesting read and you brought up a lot of good points. I think my sleep doc is one of those docs resisting change. Change is more difficult for most people as we age and my sleep doc looks to be about 70. I am sure he like many other docs will stick with what they know and as you pointed out it's their bread and butter. Someone that age also does not understand technology, is not interested in learning it, nor put any stock into it.

I think I may end up buying myself either an open box or slightly used Auto CPAP machine at some point in the coming months depending on how my therapy progresses.

APNEABOARD - A great place to be if you're a hosehead!! Rolleyes

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10-10-2015 06:20 AM
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