respironics vs resmed for plm induced flow limitations

[sheepless]

I have mixed apnea.  fragmented sleep, largely due to periodic limb movement, has been a challenge for me.  I started on resmed apap, moved to resmed asv, then to resmed vauto.  as I understand it, resmed raises pressure or pressure support against flow limitations.  this is a problem because like chin tucking, no amount of cpap pressure will resolve the non-passive flow limitations induced by plm.  runaway pressure with apap and wild and fast swings in pressure support with asv left me with aerophagia, leaks and unrefreshing sleep. I feel better with vauto but my ahi is higher than with asv.  leaks and fragmentation are increasing again. apap doesn't treat ca.  you can't adequately cap pressure support with asv.  with vauto I can cap max ipap but as mentioned my ahi is higher.  although vauto doesn't treat ca, a very high trigger helps with that, but as we know, ca varies from night to night and I still have some relatively high ca nights.  not so much to attract the attention of the sleep med people but enough that it feels detrimental to decent sleep. I'm much better than 3 years ago but still not up to par. 

I frequently read about how respironics (or is it philips?) is slower to react to oa and flow limitations than resmed because their algorithms are based on something other than flow limitations.  

my question then is: do you agree or disagree that a non-resmed machine might help to ease the problems described above?  in this context and given that ca is also an issue, is the PR (?) asv a reasonable choice?

in a nutshell, I want ipap to increase to trigger a breath against ca but not rise with flow limitations.  is there such a thing?

comments and suggestions appreciated. 

p.s. I know I need to work on alternate solutions to lip leaks (a collar worked for a couple years but less so now) and I've been trying with only partial success to get some pharmaceutical relief for plm.  meanwhile, I wonder if a PR machine would work better for me.

[Arik]

Hi Sleepless.

 
I had the same problem with my S9. I realized that the pressure increase, derived by the Flow Limitations, is doing me no good (and a lot of noise..). So I figured out what is the optimal pressure for me and switched to CPAP mode (constant pressure) with EPR 3.
 
Few weeks ago I discovered by a chance that in CPAP mode there is an option called “EPR inhale” which can be set to MED or FAST. Moving it to FAST eliminated my FL’s to almost none. I’ll write about it in a different post.
 
B.T.W: Lowenstein, which is a major CPAP vendor in Europe, does not treat or display flow limitations at all.
 
All the best,
 
Arik

[Illorum]

plm induced flow limitations

Isn't it the other way around? Flow limitations cause periodic limb movements?

https://www.ncbi.nlm.nih.gov/pubmed/11247055

 no amount of cpap pressure will resolve the non-passive flow limitations induced by plm

Are you confusing flow limitations with arousals?

[sheepless]

thanks for the replies. no takers with respect to my resmed vs pr machine question?

I do have an airsense 10 autoset but I have not seen the epr inhale setting. pretty sure it's not an option on mine but I'll double check.

regarding which comes first, some folks believe flow limitations affect plm but my experience is the opposite. before cpap I thrashed a lot, really a lot, involving most of my body including legs, fighting to breathe through more than 70 apnea per hour. but that was different: for one thing I would wake up aware of the thrashing movements; I've never been aware of plm and video of plm (not mine) indicates that these movements are often quite subtle. however, I can see my respiratory response to plm in my flow rate - a sharp inhale often followed by a moan/groan followed by a more or less uniform number of relatively flow limited breaths, repeat, repeat, repeat. there are few if any arousals preceding these (instead, arousals come after a series of plm) and pressure and pressure support of the resmed machines rise quickly against them (flow limitations) in more or less the same sequence as the plm. runaway pressure with apap and wildly swinging pressure support with asv have been detrimental to my sleep.

btw, they say correlation is not causation and I would say association is not correlation. the linked abstract is about an 'association' between uars and plm. it does not tell us anything about causation. in my view, in my experience with my own plm, closely scrutinizing 3 years of cpap data, I'm quite certain my plm flow limitations are my response to plm, not the other way around. otoh, I have plenty of flow limitations throughout each night that are not associated with my plm flow rate pattern so while flow limitations and plm might be related sometimes, they're obviously not always related. the literature I've read suggests that research and knowledge about plm is thin.

[Crimson Nape]

If you have a Resmed Airsense10 Autoset, then you do have the EPR function. You may have to enable it in the clinician's menu. If you have determined the pressure that eliminates hypopneas, then use this pressure, plus the EPR to determine your pressure setting. An example is; You have determined that 11 cm stops you hypopneas and you want your EPR to be 3, then 11 cm + 3(EPR) results in a pressure setting of 14 cm on your machine.

Good luck!

[Arik]

I assume that ResMed removed the "ERP Enhale" feature when they moved from S9 to Airsense10 as I could not find it in the 10 clinical manual. Just to make sure, check it in CPAP mode, not APAP mode.

Can someone guess what this feature was for and why it was removed? In my case, it eliminated my Flow Limitations after being "stable" for about a year no matter what I changed with pressure, ERP etc.
This is from S9 manual:
"In CPAP mode you can set the EPR Inhale to Med or Fast".
Another question to Sheepless: what you mean by"pls"?

[sheepless]

my autoset has epr settings off, 1, 2 ,3 but not med or fast. it's my understanding that some autosets newer than mine (2015) have additional settings along the lines of 'soft' & idk what else, but I'm not sure if that's an epr setting or some easybreathe type variant.

Arik, I assume you're asking about plm which is an acronym for periodic limb movements.

[Crimson Nape]

The medium and fast option only appears if you have the mode set to CPAP. The Auto mode uses medium only.

[sheepless]

well, apparently that's the case for some autosets and not others. I just pulled my autoset out of the bag to check. my device sw: sx567-0305 does not have med, fast or soft or any other setting in both cpap and autoset modes other than epr off, 1, 2, 3. as Hydrangea mentioned in another recent post, some (newer versions) have a soft setting.

[Crimson Nape]

Sheepless you're absolutely correct! I checked my AS10 (SW 567-0306) and it's no longer there. The S9 had this mode and I thought it was carried over to the AS10.