Looking for some help - almost 5 years and not feeling a lot better

[Gideon]

Not bad in finding areas with issues.
These Flow Limits are best managed with Pressure support.  On a ResMed this is EPR.

And we need a solution to the Mouth Breathing, though as long as pressure is maintained expiratory mouth breathing is not that bad, especially with your leak rate.

PS on a BiLevel is much more incremental (0.2 cmw)  and can go considerably higher than the 3 cmw that EPR is limited too.

See my notes on the charts

   
   
   

[Sleeprider]

I'm not sure I have seen someone clearly say that the Resmed Airsense 10 Autoset provides bilevel pressure identical to the Aircurve 10 Vauto, with up to 3-cm of pressure support.  When you set the Airsense 10 Autoset at a range of 9.4 to 16.0 with EPR, your actual pressure delivery will be 9.4/6.4 to 16.0/13.0 (IPAP/EPAP).  Pressure is delivered smoothly and more comfortably than anything your Philips is capable of.

Our wiki contains an example of a member's chart that had severe flow limitations.  We instructed him to turn on EPR, which provides up to 3-cm of pressure relief in exhale and works like pressure support, and those flow limitations cleared up http://www.apneaboard.com/wiki/index.php...8Resmed.29  We have seen this many times with many different members, and I think this is also an answer for you.  Let's compare the Airsense 10 EPR with the Aircurve 10 Vauto pressure support.  In the images below the flow rate is the user's respiration volume in mL/sec, and the blue line is the mask pressure in cm-H2O  Note how the mask pressure follows respiration in a smooth transition between inhale and exhale pressure, and how the pressure on the Airsense 10 works in the same way as the Vauto.  In this example EPR is only set on 2 while the Vauto is producing PS at 4.0.

Airsense 10 Mask Pressure with EPR 2:



Aircurve 10 mask pressure with PS 4.0

[happydreams]

Fred, it doesn't take very long to find issues!  Is there anything that can be managed with the Respironics unit that I have?  Don't believe there is an EPR setting in my 560.  Over the years I have fiddled with CFlex and AFlex.  I have terrible results with AFlex and have settled with CFlex-2.  By terrible results, I mean AHI's in the 3's when I was maintaining roughly 2.1 otherwise.  The difference between a 2 and 3 night is almost like night and day.

Unfortunately last night was 3.04 - so today won't be a great day...  5 minutes 16 seconds in apnea.  Does this include UF2?  I had UF2 = 1.63, where UF2 is a 50% reduction in flow for 9.0 seconds.  According to OSCAR the total duration of the UF2 events is 146 seconds, or 2 min 26 seconds.  So effectively 7 minutes 42 seconds with impair breathing last night!

[attachment=27306]

Compared to the waveforms that Sleeprider posted, these don't have comparable morphology at all.  Lot's of pointy bits, flat bits, rarely smooth at all.

Have to say, if I pick any arbitrary place in the waveform, it's not smooth, ever.  Does this mean I need to raise the pressure?

[Sleeprider]

The Philips machines are unable to match the pressure support function of Resmed. If you looked at the wiki you will see severe flow limitation in the "before" graph was completely cleared up in the "after" graph. http://www.apneaboard.com/wiki/index.php...8Resmed.29 You can achieve similar results by getting a new or used Resmed Airsense 10 Autoset, and your Philips will always leave you with this flow limitation, even with higher pressure or other Flex settings.

[Gideon]

The ResMed machines give us far better results because the EPR when treated properly mimics pressure support. This gives us a tremendous advantage when Flow Limits are involved. With PR machines the equivalent feature, flex in any of its forms, just doesn't measure up. EPR provides us with a therapeutic tool and flex doesn't. We have tried. This our preference for ResMed.

IMHO You will fee much better with any ResMed.
You are currently using a PR machine. Your only option to treat any of this is more pressure.the fact that you don't have a similar option will help to justify a BiLevel.

A properly setup BiLevel sets EPAP as the main splinting pressure for OA events then uses PS to treat everything else, thus your EPAP will be much lower than your current pressure then adding PS to treat the remaining obstructive events including hypopneas, flow limits, RERAs, and UARS. Thus resulting in lower overall pressure.

[Gideon]

I see both SR and I replied with very similar responses.

[happydreams]

The Philips machines are unable to match the pressure support function of Resmed. If you looked at the wiki you will see severe flow limitation in the "before" graph was completely cleared up in the "after" graph. http://www.apneaboard.com/wiki/index.php...8Resmed.29   You can achieve similar results by getting a new or used Resmed Airsense 10 Autoset, and your Philips will always leave you with this flow limitation, even with higher pressure or other Flex settings.

With all due respect, the "improvement" shown in the wiki is rather subtle.  The waveforms are different, but one would be hard pressed to describe the nature of the improvement analytically in my opinion.  

However, I do defer to your experience.  It would seem I am due a new machine, as I have collected data on it for over 5 years now.  Practically speaking, how do I ask my doctor to prescribe the precise machine you have recommended.  Do you think that I'd be better served getting a bilevel, as Dr. Krackow seems to recommend for UARS?

[happydreams]

The ResMed machines give us far better results because the EPR when treated properly mimics pressure support.  This gives us a tremendous advantage when Flow Limits are involved.  With PR machines the equivalent feature, flex in any of its forms, just doesn't measure up.  EPR provides us with a therapeutic tool and flex doesn't.  We have tried.  This our preference for ResMed.

IMHO You will fee much better with any ResMed.
You are currently using a PR machine.  Your only option to treat any of this is more pressure.the fact that you don't have a similar option will help to justify a BiLevel.

A properly setup BiLevel sets EPAP as the main splinting pressure for OA events then uses PS to treat everything else, thus your EPAP will be much lower than your current pressure then adding PS to treat the remaining obstructive events including hypopneas, flow limits, RERAs, and UARS. Thus resulting in lower overall pressure.

Thanks for the great explanation.  

Do you think I would be better served by a bilevel?  Should I ask my doctor for a prescription for a ResMed bilevel machine?

[SarcasticDave94]

The request you need to set before your doctor is to write script for a ResMed AirSense 10 AutoSet as an APAP or if there's evidence to support a BiLevel then the machine would be the ResMed AirCurve 10 VAuto.

The machine name shown above in bold type should be included, along with Mask of Patient Preference and Dispense As Written. I would suggest this phrase entirely might be what you need. On pressure settings, the doc can put whatever he/she cares, even default settings. You will probably have to adjust it anyway to optimize to increase the comfort and effectiveness that can be seen in OSCAR data and in your answer to "how do you feel during and after therapy?".

[happydreams]

The request you need to set before your doctor is to write script for a ResMed AirSense 10 AutoSet as an APAP or if there's evidence to support a BiLevel then the machine would be the ResMed AirCurve 10 VAuto.

The machine name shown above in bold type should be included, along with Mask of Patient Preference and Dispense As Written. I would suggest this phrase entirely might be what you need. On pressure settings, the doc can put whatever he/she cares, even default settings. You will probably have to adjust it anyway to optimize to increase the comfort and effectiveness that can be seen in OSCAR data and in your answer to "how do you feel during and after therapy?".

Thanks for the explanation.  It's very helpful.

Can it be stated (truthfully) that what would make my condition 'better' is more pressure support?  That more PS would reduce the incidence of disrupted sleep?  And a bilevel machine could offer this with a lower overall pressure required?

I don't want to fight with insurance companies, just want the most effective solution for myself.  If that's a bilevel, the machine needs to be self funded, so be it.  With that stated, is there any non-financial reason not to ask for a bilevel prescription?