Where can one find a respiralogist?

Where can one find a respiralogist? - Printable Version

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Where can one find a respiralogist? - sventory - 09-06-2018

I came across a thread (that I now can't find) where someone said they kept having problems with CPAP, until the owner of the CPAP company themselves took a look in his mouth and immediately said he needed a BiPap, and then started getting some relief. Where can I locate someone who can do that? Googling "respiroligist" in my area doesn't yield anything but pulmonologists.

I suspect I may need BiPap, but the sleep doctors in my area (central IL) are useless and don't even really look at the machine data and can't even think past anything beyond "your AHi is low must be something else"

RE: Where can one find a respiralogist? - Walla Walla - 09-06-2018

They're both the same thing.

RE: Where can one find a respiralogist? - Crimson Nape - 09-06-2018

Can you post an image of your Flow Rate that is zoomed to a 2 minute segment? Also, I'd consider looking for an ENT for a "look-see".

RE: Where can one find a respiralogist? - sventory - 09-06-2018

I've gone to an ENT. One that was utterly useless, who said "everything looked fine". Then I went to another in Chicago, who did the same scope and said its very narrow back there and most likely tongue collapse at minimum. So not sure what else they will tell me. I've had a DICE where they confirmed tongue full collapse and almost foll collapse of the velum as said in the report.

So I should be looking for a pulmonologist? Great, because the previous one I had was horrible and delayed my diagnosis. Ignored my first sleep study with a high RDI because it had 0 apneas, suffered for 3 more years before I started having actual apneas. Seems like I had UARS before apnea and this guy totally ignored the signs telling me its all in my head. Then after CPAP when I told him I'm still not sleeping well, he just said "there's nothing more I can do, don't come back more than once a year at most".

I'm at work but will post a 2 minute segment when I get home. My flow curve even without any events doesn't look normal (it's not a curvy wave).

RE: Where can one find a respiralogist? - sventory - 09-06-2018

Crimson Nape, here is my flow rate zoomed into a 2 minute period roughly for multiple periods:
[Image: 5rQxGPM.png]

Def sure I was asleep during the second one, not sure about first.

[Image: Gf5JreE.png]

Sometimes they will look like this too:

[Image: zPXdot5.png]

More curved but less high/low.

For further reference here are some summary days for me. I have 2 custom flags, Flag 1 which is 20% restriction for at least 5 seconds, and Flag 2, which is 50% flow restriction for at least 5 seconds. You'll see in these summaries I actually have a ton of Flag 2s throughout the night, including many greater than 10 seconds, then why doesn't it flag it as hypopnea?

9/5:
[Image: qYocVeh.png]

9/4:

9/3:

9/2:

Lots of times when you see the pressure spike, that is when I am asleep for sure, such as 9/2 between 5:30-6:30. But I've tried putting the pressure to 20 and it gives me lots of air in my stomach which is someone uncomfortable and doesn't even prevent stuff, as can be seen on 9/3 around 9am, manually put it to 20 and still had central, hypops, and user flags.

My sleep is so horrible and fragmented I just don't know why the APAP isn't working. Anything these pictures can tell you? Do I need Bipap?

RE: Where can one find a respiralogist? - Sleeprider - 09-06-2018

Sventory, you have moderate to severe inspiratory flow limitation that disrupts your sleep. While this does not register as an "event" or apnea that the doctors normally look for, it can be very disruptive to your sleep. It can also result in significant oxygen desaturation due to the time and extent of the respiratory restriction. Here is a wiki article that describes using the EPR on the Resmed Airsense 10 Autoset to mitigate flow limitation. http://www.apneaboard.com/wiki/index.php?title=Flow_Limitation

In more severe cases like yours, a higher pressure support is desirable. Here is an article by Dr. Barry Krakow on our Wiki that explains his rationale for using bilevel for treating this condition. http://www.apneaboard.com/wiki/index.php?title=Flow_Limitation/UARS_and_BiPAP I agree with your conclusion that bilevel is the most appropriate treatment for your condition. I encourage you to pursue this with your GP, pulmonologist or anyone else that will listen and write an appropriate script. It's certainly not a risk to use bilevel vs CPAP, and can have a lot of benefits.

My personal story with bilevel is that I was using auto CPAP and purchased my first BiPAP on Craigslist for $300. I used the data from that machine with my personal feelings of better sleep and lower event rates to get a prescription for bilevel from my primary physician. He reviews my compliance and results annually and continues to update the prescription as needed. Sleep studies are pretty worthless, as well as most sleep specialists. Find a friendly doctor that will listen to you as the best source of efficacy, and you will have mined gold. Meanwhile, consider self-financing a used or discounted bilevel so you can prove your case. If you want to do it the hard way, I suspect a recording oximeter will show these flow limitations are a problem. You don't have to tolerate this, and you can take steps to make it better. Start with maximizing EPR on your machine while maintaining EPAP pressure. If that does not provide enough relief, the bilevel will work with higher pressure support than the 3-cm your Resmed CPAP provides. You may need to self-treat or purchase an affordable bilevel, or perhaps you can persuade your primary or other doctor to cooperate. I think my initial investment in the first PRS1 BiPAP Auto was well worth it to make this my prescribed treatment.

RE: Where can one find a respiralogist? - sventory - 09-06-2018

Thanks Sleeprider. It is such a relief that it's easy for you to see. Why the #$%#$ can't anyone see this then? Why does this knowledge seem so rare from supposed professionals? I've suffered for so long and still haven't found relief. Can you clear up some things for me in terms of interpreting the flow limit curve. When I am inhaling, should the flow rate by positive or negative? I assume the values are %? but % of what? And so then on my flow curve, does it look like its dropping to 50% on almost every single breath? That sounds quite bad.

If you are saying I have inspiration flow rate limitations, why would EPR help? Isn't that to make it easier to exhale? I used to have it on EPR 3 all the time until recently just to try something different. My mom said she has it off and sleeps worse with it on. A sleep tech who did my EEG 2 weeks ago also said EPR causes too many issues she has seen. What should my settings be based on what you see above? 20 pressure with EPR3?

I will just purchase a machine, I want relief. What is the difference between this: resmed-aircurve-10-vauto-bilevel-machine and this:resmed-aircurve-10-s-bilevel-humidair. I couldn't find it in the descriptions? Commercial Link Removed. Instead check Supplier #1 for above products.

Thank god for your help sleeprider. I know I ask a lot of questions, sorry just trying to understand so when I go to my doc I have more ammo.

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RE: Where can one find a respiralogist? - Gideon - 09-06-2018

An excellent reply Sleeprider. I was going to respond with "significant flow limitations" but you beat me to it. Excellent articles explaining it.

Fred

RE: Where can one find a respiralogist? - Crimson Nape - 09-07-2018

sventory,
I didn't forget you after making my initial request for your flow charts, but the excellent posts by other members far exceed anything I could have provided.

Good luck and keep us up to date on your treatment.

RE: Where can one find a respiralogist? - Sleeprider - 09-07-2018

Sventory, you can't post links to commercial sites on Apnea Board. You are asking what is the difference between the Resmed Aircurve 10 Vauto and the VPAP S. Similar to auto CPAP vs fixed CPAP, the Vauto allows you to set a minimum EPAP and maximum pressure and a pressure support. The Vauto automatically adjusts pressure up or down while maintaining the pressure support (difference between IPAP and EPAP). The VPAP-S allows you to set the EPAP pressure and IPAP pressure, but does not change pressure, even if you have indications of obstruction. Both work well, and can treat your flow limitation. My personal preference is for Vauto, however you may find fixed pressures to be just as effective. As you know, any auto machine will increase pressure in the presence of flow limitation, so when that is what we want to target, we often cap the pressure or set it to fixed mode. Since the Vauto offers both modes, I think is the best option.

In addition to being able to support separate IPAP and EPAP pressures, these machines also let you adjust the sensitivity to trigger IPAP and cycle to EPAP. They also allow the minimum and maximum times for inspiration to be set. These fine-tuning adjustments can help when inspiratory flow limitation is present.

What these machines will do for you is to provide more pressure during inspiration to relieve the restriction you are experiencing, and help to give you a more normal appearing flow curve. Currently, when you start inhaling, your flow rate rises above zero normally, but the flow rate peaks at about 30 mL/second in the example below. Normally the flow would rise smoothly to somewhere around 60 to 80 mL/second. This means it takes longer for inhale to be completed, and the flow restriction imposes more effort. By unceasing pressure support, the restriction can be reduced or eliminated with less respiratory effort from you. It's that simple. To better see this on your graphs, right-click the left side of the flow rate chart over the words Flow Rate, and select Dashed lines. Select Dashed line at zero. this is the zero flow crossover. All flow above the line is +mL/second, and all flow below the line is -mL/second. You can also override the Y-axis auto setting and set the Y axis to a scale of +100 to -100 or even less. This will make the flow rates much easier to interpret.

Finally, do some shopping around. The links you provided to Supplier #1 are the manufacturer's minimum advertised price (MAP). You can find lower prices, but i usually involves "open box specials" like you might find at Supplier #2 and lower prices might be quoted if you call by phone than simply order online. Supplier #2 is offering a "Gently used Aircurve 10 Vauto for $799. Since that comes with a warranty and service it is a pretty hard deal to beat.

[Image: Gf5JreE.png]

In this next example the flow limitation is even more severe, with peak flows less than 20 mL/sec resulting in hypopnea and the arousal (large spike in flow rate near the end of the sequence) where there is obvious recovery breathing that attempts to correct what is likely an oxygen desaturation. You may not even be aware of the arousal, but your body is not getting the rest it needs as you struggle to breathe, desaturate and arouse repeatedly. This is just as bad as apnea.

[Image: 5rQxGPM.png]