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Why don't these flow rate curves count as flow-limited?
#11
RE: Why don't these flow rate curves count as flow-limited?
Secondwindcpap (supplier 2) offers used and new in box vautos at a reasonable price that includes warranty and they ship to you. I would trust them before driving a long ways to buy from an unknown person, I tried to buy a used machine once and it was wrongly represented and wouldn't turn on have to be a lot more careful buying from some random person.

From the data you have posted in other threads you have nearly constant flow limitations, not just during periods of leaks. For example both examples in this thread show constant untreated flow limitations that are causing multiple RERAs. Almost every spike of flow rate in your data is a good chance of being a RERA due to your high flow limitations.

http://www.apneaboard.com/forums/Thread-...-flow-rate

It is really quite simple, you settle with what you have if you think it is doing a good enough or you listen to what multiple of us have told you already and you try treating your untreated flow limitations. Frankly there is no point discussing this further as you only have two options, try to treat or don't.
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#12
RE: Why don't these flow rate curves count as flow-limited?
Well hopefully help is on the way! Found a craigslist vauto and I paypal'd the seller payment this morning and he's going to ship it out to me on Tuesday.

2SleepBetta -- ok, I'm still struggling a bit... Does this picture help? It's a closeup of the last 10 breaths leading into the arousal at the end of the 3-hour-long slow-motion hypopnea:
   

(closeup of this:
http://www.apneaboard.com/forums/attachm...?aid=33317
)
Which brings up the obvious question... I can see the exhale in the green lines, and the inhale in the blue lines -- but how do they count that section between those two, where it just flutters along next to zero? Is it part of the inspiration? exhalation? neither? It's like I have to wait for the EPAP pressure to recover to the IPAP pressure before I can manage to start the inhale?

And and even more obvious oddity: 
I just get more confused...

I call this breathing "marching llama breaths". Especially when there's an "m" shape to the inspiration that looks like the llama's ears, and the expiration looks like the llama's feet are, and then there's a long area that you could saddle up and ride! (If llamas weren't so mean that you can't ride them!) And that seems very significant to me, because when those "llama backs" get longer than 10 seconds long that's called a "central apnea."



Another obvious question-- my llamas are marchicg to the future, with everyone else's seems to march into the past. Anybody know what that means?


(Also stumbled upon a vauto for $95 in Ohio, advertised as untested, no idea of the condition, as there's no power cord. I'm wondering if I should grab that, too -- I can do some electronic repairs, and the hubs builds weather detection electronics for his research. If I can get two working vautos maybe I can help out somebody who's had their PR bipap recalled?)
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#13
RE: Why don't these flow rate curves count as flow-limited?
It helped tremendously for you to flatten out the cardiogenic effects that obscured the beginning of many inhalations and cut the ratio of the curve trace width (in pixels) vs the I and E scaled widths. The change in ratios is striking. I won't take time to check but think the error might be fairly consistent--a combo of randomly shaky hands on the mouse, the thickness of the curve trace vs shorter wave widths and, possibly, some distortion of the FR curve and perception of it all when zoomed out. Anyway all ratios are much improved in that series as would be true of the preceding waves.

It looks like you would have ratios close to those of the maximally dosed normals when their ventilation was cut the most to cause severe limitation for the study.  

   
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#14
RE: Why don't these flow rate curves count as flow-limited?
In theory the green to blue is still exhalation, its the period where the majority of exhalation has stopped but inhalation process has not yet started. The little bumps during this time are cardiogenic oscillations caused by arterial blood flow in lungs. Cardiogenic oscillations do screw up inspiration and expiration times reported because similarly to flow limitations these machines are far from perfect and they don't have AI level interpretive capability to determine if the bump crossing 0 flow line is a breath attempt, cardiogenic oscillation or some other phenomenon affecting flow rate (twitch from PLM, arousal and many more).
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#15
RE: Why don't these flow rate curves count as flow-limited?
To cut it short: I would really be interested in how you would deal with a VAuto.
I tried to skim through some of your other threads - but most of the screeshots there are gone as well (at least for me). But anyway my english is not good enough to grasp the subtle changes (mostly between the lines) in how you feel. From what I could pick up it looks like you have enough on your plate which could attribute to (or be the main cause) of 'bad sleep' - so I would assume that more pressure support would not result in "better" sleep (naturally^^) but you never know until you try ... on the other hand I would be equally interested in how you would do with a more moderate reacting device (like Löwenstein / Weinmann ... or under normal circumstances Philips - but that one is no valid option nowadays^^) - although I have my doubts there as well that Hypopneas are your only problem or actual treatment of those would make such a difference. (and you clearly have Hypopneas - although I have not found enough usable Screenshots from you with complete nights to estimate the amount or possible impact)

It's a real pity that I cannot even see the pictures in this thread - but it looks to me somehow related to the current posts in the "FL-Index" thread (from Post #41 to Post #49), so I leave my techno-blabla here and not in the other thread Huh

This screenshot is quite intriguing:
[Image: attachment.php?aid=33215]

or in detail here or here

Around 6 minutes with a respiratory flow around 5 l/min and a respiratory rate around 11 per minute. If that would have been your breathing you wouldn't be alive to tell us (unless you are really(!) small / petite) - that is only slighty above deadspace ventilation.
What is fascinating is what your device makes out of that: The airflow was too small to get detected as breathing - your tidalvolume and your resp. rate actually go down to 0 Huhsign
But at the very same time there is absolutely no FOT-Signal and your flowlimitation actually increases ... and to my surprise not even a single hypopnea flagged. (as usual I am clearly with you - if THAT is no Hypopnea what does one have to do? Oh-jeez )

As one can (clearly) see in the SPO2 you were (in reality) breathing normally - reducing all that data to just random garbage. Dont-know
(and that is actually important! - the data does not make any sense - no need to dissect that even further[Fullstop])

(06-28-2021, 05:35 PM)cathyf Wrote: I'm still totally unsure on how to interpret the leak numbers-- the leak is in the 6-7 range which I thought was supposed to mean "acceptable". I have no idea whether the leak represents mouth leak, mask leak, or some combination -- is there some way that you can tell?

The leak of something about 6 liters per minute is just off - I would say way off! If you look at the end of that episode you should see a couple of breaths which should be below or above the 0-flow line - maybe not completely - but the amout of air from inspiration should not be equal to the amount of the exspiration.
There is no real way that you can get back to the total flow measured by the device. Either the device reports that data (that would be raw data) or it is gone forever. ResMed estimates somehow the ventflow from the mask - depending on the mask that might not even be always constant for a given pressure (for example the DreamWear produces quite different results if you're on your side and half of the 'air'-frame is squashed - I would assume the AirFit 30i-Systems behaves equally).

Now there are a few problems with leaks:
first of all: the leak itself is never(!) as small as the device makes one believe. If a leak is present it would be just stupid to assume that the intended ventflow remains steady - what is much more likely to happen is: the intended leakage through the ventholes decreases as the leak increases - so in reality the leak is ALWAYS bigger.
The other thing is: there is no way a machine can detect very short leakages - there simply is no way. For the machine the absolutely shortest timeframe for a leakage is the duration of a complete breath. (The math behind that is actually very simple: what goes in has to go out (your respiration) - or in other words: in the average over a total breath your respiratory flow is zero and whatever remains is the total leakage .... if you average that further and make just a few assumptions you got the intended ventflow and thus the unintended leakage ... in theory - if you miss the intended ventflow you miss the unintened leakage [and so on])
You can double-check that easily in the "clogged P10" thread - there it was under-leakage or a decreased ventflow which decreased further during the night. (easy to spot on any device with a total leakage or a total flow - after one considers that as a possibility^^)
Personally I would consider partially blocked ventholes quite normal with CPAP-Therapy ... there are quite a few masks where nearly by design parts of the venholes are blocked on your side or belly^^

And then there is another thing: real leaks are highly pressure dependent! There simply is no such thing as a leak that has a constant flow if one actually breathes in and out during that time. This holds true for the intended ventflow as well as every unintended 'real' leak!
The pressure is measured at the outlet IN the device - not in the mask! The difference might not be that big but if you are seeking and talking about very subtle changes in the flow even a few ml/s become important Thinking-about
With FFMs one can sometimes see that clearly at the beginning if the breathing is strong enough to open up the AAV (which actually can happen as well after severe enough apneas).
This gets really complicated if the leak nearly seals itself during inhalation and opens up again during exhalation.
... and of course you can always top that and just introduce a highly dynamic pressure in the first place. (let's just call it: EPR Wink )

... or if there are some funny things going on with nasal masks Too-funny ... there you have a really big "vent" / leak / seal which you can open and close (the mouth^^)

In the category of data that does not make any sense my absolute favorite is still: https://forum-schlafapnoe.de/download/fi...&mode=view
(that is a german screenshot: fließrate = flow rate; Pulsrate = pulse in bpm ... and there was a pacemaker involved ... what is astonishing for me is the flowrate of values well above 70 liters per minute Oh-jeez )
No way to extract the real respiratory rate there as well - whatever one would guess does not make any sense. (by the way: that is not a problem with the data or the device - the data from a Prisma 25ST (capable of Auto-Tri-Level) was likewise)

So, I would not care too much about data as long as there are leaks. This does not really mean that you need to make all your leaks go away - that would help a lot of course - what I mean is: as long as you have leaks (and it does NOT matter how big those leaks are) you are in the guessing range. If you want to actually and maybe even exactly measure anything then make sure you minimize all errors - in case of CPAP that means leaks ... if you are interested in flowlimitations that means 0 leaks (and 0 means exactly 0,0000000 and not something below the amount of a breath per second (which roughly translates to 24 l/min))

But let us not simply stop there Dielaughing If I(!) look on that picture: http://www.apneaboard.com/forums/attachm...?aid=33216 I do not see those really bad flowlimitations Huh
Maybe someone with a big marker can point me towards them ... at best I could see (or more precise: imagine) some snoring.
Okay I have to admit that a peak flow of about 5 liters per minute would be the very definition of a flowlimitation Laugh-a-lot

The real funny question here is: as the device is no longer able to determine the breathing, what does it count as 1 breath? (and if we take a couple of real "breaths" as 1 that one is definitely distorted or a bigger flowlimitation^^)

... well: we always see what we want to see like

But this answers the question where/when the AirSense switches / triggers the IPAP - looks to me as somewhere around 80 ml per second (or around 5 l/min).

Speaking of triggers Too-funny - what triggered me was:
(06-28-2021, 09:46 PM)cathyf Wrote: As has been pointed out several times in this thread, sleep doctors don't care at all about flow limitations, while device manufacturers have the devices largely focused on reacting to them.

That is simply not true! There is 1 (in words: one) manucacturer that does that - and that one is called ResMed.
There a few or couple dozen manufacturers worldwide - by far not all are reacting only to flowlimitations! (from the few I know ResMed is in fact the only one ... well maybe the one chinese company that just copied ResMed does as well - although I have my doubts that they are still doing that (that way))


I know this all doesn't really help you ... as I said: I just skimmed (roughly) through some of your threads. If I understood all correctly (from the very few and only recent images I could see) your diagnosis of 'just' OSAS seems to be only based on "positional apnea". Normally OSAS is a no go criteria for UARS ... but: noone really knows what "positional apnea" really is or how / why a cervical collar works. (at least to my knowledge ... and I can increase the confusion even more with that: https://downloadcenter.hul.de/download.php?id=5157 - pay attention to the 'closed centrals' - looks awfully familiar?) ... although obstructive apneas and UARS might not be together maybe centrals and UARS are?
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#16
RE: Why don't these flow rate curves count as flow-limited?
That example is a clear example of a RERA. It doesn't get flagged as a hypopnea because it decreases in amplitude too slowly. A hypopnea is defined as a decline of at least 50% flow rate for 10 seconds. The total decline is around 50% but it occurs over 3-4 minutes time so is not a hypopnea, it is just flow limited breaths that eventually ends in a RERA. A RERA didn't get flagged because these machines are not capable of scoring most RERA's. Resmed seems to only score RERAs if there is a combination of flow limitations and decreasing amplitude breaths followed by a spike (arousal breathing), when the flow limited breaths are flatlining like this prior to arousal they almost never get scored.

A couple of the other flow limitation examples you linked to are classic examples of the type of flow limitation Cathy has. They don't show up as the classic double peak flow limitation but they are flat topped low amplitude breaths and a lot of them exhibit signs of inspiratory snore as well (like the one you linked to) strongly supporting obstructive restriction. What is interesting to note is how the flow rate drops so low that it stops triggering pressure increases which of course makes things worse.

Vauto will not only allow higher PS to keep larger fuller breaths and avoid these moments of slow flow rate decay but the timing controls (specifically tmin and trigger sensitivity) will ensure that every breath receives a minimum amount of pressure support for a certain time which will also help avoid these decays.

The only thing I find somewhat confusing about cathy's data is how SPO2 level drops only very minorly during these periods of severe flow limitation.
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#17
RE: Why don't these flow rate curves count as flow-limited?
(07-04-2021, 02:19 PM)Geer1 Wrote: A couple of the other flow limitation examples you linked to are classic examples of the type of flow limitation Cathy has.

I'm sorry - actually they should have linked all to cathyf's screenshots from the very same time - just different zooms.

Regarding the event I would say cathyf herself pretty much nailed it:
(06-26-2021, 01:13 AM)cathyf Wrote: I would say that's not an "event" it's a "lifestyle" LOL

No matter how you put it - that "diminishing flow" is and stays just data-garbage ... there simply is no other interpretation for that. (taht makes any sense - except if cathyf would be really, really small) the anatomical deadspace in a normal adult is around 30% of the respiration or something around 150ml - I don't see a way how one can survive over such a prolonged episode with a tidal volume below 200ml and a respiratory rate around 11. (maybe with just 1 or 2 really deep breaths per minute but not that tiny bit)

If in doubt just check the SPO2 values - there is no biological way to maintain O2 saturation without actual breathing over such a long time.

RERA or not does not matter - it ends with a SUDDEN END OF LEAKAGE (usually one is or gets awake during such a thing) - you can clearly see how the device messes up the flow rate (due to the sudden change in leakage) ... afterwards comes another leakage (but clearly different) - so there was no complete awakening ... movement in halfsleep or arousal due to the leakage (and maybe as a result increased breathing effort) .. in the end it does in this case not matter because: garbage in - garbage out.

Machines that do score RERAs are not really better ... there you end up dismissing the majority as (movement) artefacts - if you want to get those scored you actually do need the EEG-Data and by that the arousals and you need EXACT timing (arousals are quite normal .. a healthy person has plenty of them over the night - once that happens the apnea threshold and respiratory drive changes so of course there is a change in the flow - the important thing is: what induces what and what came first) ... just from the flow you simply see to much movement artefacts^^

But of course a VAuto could fix the data shown here - it would be really interesting if that would change anything about how cathyf feels or how refreshing the sleep would be. (as mentioned: noone really knows what and why "positional apnea" really is and how and why a soft cervival collar works - so I would not really count that as OSAS - thus keeping the door for UARS and / or flowlimitations open^^)
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#18
RE: Why don't these flow rate curves count as flow-limited?
Her numbers are always low (TV around 350 so deadspace around 100), either she is small or potentially they are understated by the machine. If I remember right the machine is overdue for replacement so I assume some stats/data may be a bit questionable.
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#19
RE: Why don't these flow rate curves count as flow-limited?
Ok, the "Cathy really really small" made me smile Big Grin 

Because in some sense I am! I started therapy in Oct 2014 at 267lb. By mid-2016 that went all the way down to 137lb.

The comment piqued my curiosity so I went back to 2014 and rummaged through my data and found one of those long sustained flow limits from my fat-girl days.

   

Note that this was in the very early days, with pretty different settings. This was my experiment with constant pressure.

Ok, to back up here... I'm a data-driven gal (I lost 130lbs over 16 months by recording everything that I ate -- down to 1/10th of a gram! -- which I am still doing 6+ years later. (And I've kept the weight off, ok, modulo the covid-5...)) I downloaded SleepyHead-Testing-0.9.8-1-MacOSX.dmg on Oct 8, 2014, and my first night on the machine was Oct 10, 2014.

Yeah, I'm a little OCD.

Anyway, you can see EPR is off, constant pressure is 12.

From the very earliest days of looking at data (Sleepyhead then), I've been saying "What the heck is this 'flow limit' crap, why is my machine getting its panties in a twist over them and pegging my pressures to 20 if I let it, even though if I don't let it go above 8-10-12 I get big flow limits but no events?!?" As early as November 2014 I was at a different apnea discussion board asking if there was an "ignore flow limits" setting on my Airsense 10 because in my data it looks like flow limits are harmless!

It cracked me up when TBMx said that I triggered him with the comments about "all the device manufacturers" with the laser focus on flow limits when it's just ResMed. I'm not sure where I got the idea that it was more than Resmed, but it must have been here because up until recently I thought that was a Resmed thing but didn't really know because my only experience is Resmed. (Of course after the dreamstation debacle we may very well be headed to "all the device manufacturers" is a synonym for "Resmed" !)

I'm still processing a lot of what you guys are telling me...

This shot here: http://www.apneaboard.com/forums/attachm...?aid=33174 is a 3-hour segment of this night here: http://www.apneaboard.com/forums/attachm...?aid=33156.

Take a look at this perspective on the 2am cruising-along-at-5-for-6-minutes thing:
   
I did something pretty radical here in that I changed all of the y-axes to exaggerate/zoom on the values that are local here (and weird here!) The small leak is either 1.2 or 2.4 -- which is clearly the resolution of the measurement.

I think that maybe I'm not going to get a good reading off this machine with a nasal mask? I have both the resmed and phillips versions with the hose-on-top-of-head variation, where when I'm on my side I'm pinching off half the air feed into the mask. The Resmed and Phillips marketing materials both have vague talk about how everything is rainbows and unicorns and don't worry about it the machine can read the data just fine with you sleeping on half the hose. I used the dreamwear full-face mask for 2-1/2 years, and had some weird long time periods where the tops of the inspirations are between 7-8 -- is that as impossible as 5?

That setting the Flow Rate curve y-axis to 0-10 is interesting. I just paged through a years worth of data, and at the zoomed out level, 0-10 is totally black everywhere that there are no leaks. Except for this interesting example here (which I'm showing with a more normal zoom -- the 0-10 is good for seeing them while paging quickly through)
   

Ok, yeah, when the tops of the inspiratory curves don't make it above 5-6-7 the machine should be calling it an OA!

(My next thought -- since my scheming machinations are never too far from my mind -- is to send a mychart message to my sleep doctor and say, hey, my machine had a night that it recorded that I was not breathing for six minutes, and it didn't even score it as an apnea or hypopnea. Can you write me a prescription for a new machine?!?)

I need to stew on all this some more. In another couple of days I should have my vauto, and maybe it will become clearer what is happening -- is it a malfunctioning machine? Bad mask fit?
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#20
RE: Why don't these flow rate curves count as flow-limited?
A few knowingly trivial responses to a number of posts in this thread along with these disclaimers and more: my nearly 6 years of xPAP  treatment have been about half and half by Resmed's Autoset and VAuto and what little I know is centered on that experience and on  what I, an OSA and flow limitation student, have learned from often-limited understanding of many relevant research papers, AB threads and a few Resmed patent applications. Resmed, and I suppose other brands, cite other device brands' methodologies and recognizable limitations in their own patent applications.

1. On the lighter side, I think I see cathyf's marching llamas, with their large necks, marching toward the future, but need help remembering llamas going toward the past. Help! Smile

2. Somehow I cannot see the graphics, in this thread, that are referred to as showing green or blue curves or boundaries. Again, help please.

3. It would be instructive, TBMx, if you would post, here (a thread elsewhere seems more appropriate) to show relevant outputs from your or others' blower devices and from either or both your OSCAR and other device's related software. It would be helpful to see your full discussions and illustrations: explanation of how your most favored machine brands perform and present OSA and reduced-flow information in a more rationally coherent and well founded, if still imperfect, way for cathyf's specific kind of case-- how those technologies do better than the Resmed Autoset and Vauto. Further, but related, are there other $-disinterested forums where their lineups of real, seasoned lay experts preponderantly favor a different technology than RM's  for dealing more effectively with most--not all--cases of OSA and flow limitations? It would be most helpful to read substantial and provocative findings and  research challenges of Resmed OSA and flow limitation therapy in order to enlarge our understanding of the topic.


4a. The long, slow, narrowing taper of one of cathyf's FR-Inhalation amplitude graphs--as I and others, most lately Geer1, have remarked about--seems difficult to grasp, for many including me, because it can, as we see, coexist with a continuous high level of only slightly varying flow limitation. IMO, such variations as there are, stem from patent-discussed/protected fuzzy logic combinations. Those again here, as I understand them, sort out and prioritize small wave shape, respiratory rate and flow volume variations to first of all make real time, timely, best-judgment pressure adjustments upward if necessary to maintain good therapy and then lower pressure as appropriate.. 

4b. Actual, serious flow limitations, I believe, can and do maintain/continue a FL flagging even in instances where real limitation has gone to zero or dropped sharply for, say, 2 to 4 seconds--but the actual non-limitation dwells at zero or a lowered level for too short a time to exceed the preceding FL's algorithm-set minimum or other preset time-duration threshold for that preceding FL. That preceding FL's duration algo-set overstatement  bridges over and obscures the "undetectable" near zeroing or drop of the flow limitation for a time. This maintains/sustains the appearance of periods with unbroken, unusual FL flagging. (I may have seen a 4 or 6 sec. duration FL, but those would be the shortest for the FL flag, which is based on sampling at 0.5 Hz., as I recall.) It is one of the problems/limitations of inadequate resolution which stem in part from prioritization among judgement calls for continuously responsive therapy, costs and complexity of onboard computing, device pricing, sizing, clinician and MD training, device adjustability, insurance, yada yada. 

4c. The long slow taper in one of cathyf's FR amplitude graphs is because there are not large enough (time or/and volume) changes of inspiratory flow-rate  to trigger a FL according to Resmed's fuzzy logic sensing settings that trigger a flag when a large enough change occurs within a certain pre-set or dynamically set time span; also, because of the bridging effect from built in time resolution linits compromises come into play.
 
5. I, too, have remarked at how cathyf has maintained normal SpO2 levels despite long periods of low FR, TV and MV. Part or all accounting for that has to be increased duty cycle (higher I/E) and, yes, deficiencies in detection and accounting for leaks. As I understand, such low values are often partly offset by higher RR, especially for persons with co-morbidities.

Two more things I ask you, cathyf, to consider posting, and I thank you for stimulating a lot of interest in and probing of flow limitation and its varied presentation: 

1. To see that same 10-wave set we last posted along with the corresponding TV, FL MV, MR, RR, I and E, all maximally expanded to just totally fill the full y-extent of their individual view frame and, similarly, fill the whole screen-view space. If necessary, omit the FR curve I annotated more accurately the second time.

2. Too see the most puzzling 10 -20  wave series you see from the same graphic TBMx showed/linked, along with those graphs above and FR, where FR was near 200. If necessary, omit from it MV or/and RR.

Of course, this and many threads are all about numbers and our trying to understand more from them, from what we see and feel, that may help us focus and act where and how we should to improve restfulness of our and others SDB affected sleep. 

For example, Geer1, I believe once responded waaay back to a post of mine regarding FL with findings he presents here about diet-- about dairy particularly for me an all-dairy  lover and once a youthful cow feeder and milker. Geer1's persistent and cogent writings then and here (as I only intellectually accepted them back then) and my understanding of him now, has only now caused me to seriously consider a dairy free trial. Only now, because of him, do I remember and see the potential significance of the fact I had asthma and rheumatic fever as  a pre-school child and then had to stay in bed--there draw P-51s, 38s, 40s, Corsairs and B-24s--and eat only a few things, including evaporated milk as our MD kept and monitored a botanical garden plot of allergenics in a lattice plot of pin pricks, smears and dustings on my back in war-time, pollen rich Yakima, WA, where dad, blind in one eye, taught young AAF pilots during short military use of Perry Institute. 

What prompted need to use only that then-"icky" condensed milk? Our MD? (Were Fauci and his ilk only gleams in their four eventual parents' eyes then? Thinking-about Or was it mom who spoke of starving children in India who would then glady eat what I did not want on my plate?) Or was it a milk rationing thing? Last of my generation, I can't remember or ask family about those facts. 

Gotta consider a non-dairy trial, all the more personal reason to sharpen up understanding of SDB and other health issues while still blessed to enjoy life.  I  seemed to outgrow almost all allergens. But we adapt, as I think cathyf has, when we don't know better and we become inured to our "normal". I didn't even know I had severe SDB until tested in 2015 showing RDI 58. My wife's "turn over" and complaints of snoring and gasping beside her came to be seen as a serious matter for my first time.

Explanations I offer are largely my conclusions as a slow learning, opinionated, and low-intermediate student of  these matters. These are just my opinions for consideration by other flow limitation sufferers trying to understand therapy and whether and how their needs are being met..
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