Don't know what I don't know.... newbie...

[jimcaffey]

Sleeprider, 

Thank you for the explanation.... if I could test for understanding....(interlaced in your reply) Let me apologize in advance if my questions are splitting hairs, I am not challenging your thoughts, it is my wanting to have a better understanding of whats going on and how the equipment we use can effect it... 

Jim, welcome back. Your progress is very encouraging, but if you really want to take it to the next level, it's going to take a different machine.  RERA is related to flow limitation and the Philips Auto CPAP does not provide any useful tools to address it. The Resmed Airsense 10 Autoset and, better the Aircurve 10 Vauto do.
By next level would it be fair to say, "more complete sleep"? A sleep with fewer sleep interruptions with the reduction of RERA, H and FL episodes, correct? 

The RERA, flow limitation and hypopnea all arise from airway resistance that can be compensated or overcome by pressure support (the difference between inhale and exhale pressure).  
I could rephrase that by saying I am still experiencing a limited effective ability to inhale and exhale, as evidenced by the flat peaks of my flow rate and ragged (labored?) exhale as a result of not airway obstruction, per se, but resistance, in my breathing... correct?(I see both much better in closeup on the charts below)  Could that be envisioned as not necessarily an obstruction of my airway but a narrowing of my airway? 

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The Airsense 10 Autoset is an auto CPAP but has up to 3-cm of exhale pressure relief that we can leverage to treat these conditions. I have the Philips set at 9cm of pressure, as a base, am I correct in interpreting this as that the Philips is pumping a minimum of 9 cm but is not flexible enough or sensitive enough to change as quickly when compared to the others machines mentioned, Correct? This is evidenced by the ragged exhale curve, and that the other machines could "smooth" the exhale by lowering the pressure a little (up to 3cm with the Airsense 10 etc.) upon exhale... correct? Could the flatness of the flow curve at the peak be further interpreted as my airway resistance causing a "delay" in my ability to exhale? and further, that the quick addition or subtraction of up to 3cm of pressure applied quickly would reduce the delay in exhaling? The Aircurve 10 Vauto has not pressure support limit, and additional timing tools to increase or decrease inspiration timing and trigger sensitivity. With either one, your AHI would improve, but more importantly, your comfort would increase to the point that therapy would become transparent.  You have flow limitation, and if you zoom in on your flow rate chart, you will see you have a lot of flat-topped inspiration waves, and expiration is not comfortable. We can see it because of the ragged appearance of your flow-rate chart. 
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[quote pid='330071' dateline='1579565541']
It's up to you, because insurance is unlikely to cover the upgrade given the fact your "numbers" show you are well treated and have no medical necessity to change. Lots of machines online at Craigslist, Offer-up or other market places, but if I could put you on a Vauto one day, you would not wonder why I'm such an advocate of those machine; you would know why. I will research these sources, thank you. And thank you for the interpretations and advise. One more question: Would the Periodic Breathing episodes I still experience also be addressed by the additional sensitivity or timing tools of the other machines mentioned? 

thanks again,

Jim C.
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[jimcaffey]

Hi Hydra, 

I am in the same boat. I concluded that this is a marathon and not a sprint. when I started, the first night I slept through the night. That hadn't happened in decades, and on my back to boot!. It was an immediate improvement over what I had been experiencing but as someone rightly said on this board, "If I'm going to wear all this crap at night, I want as near to zero AHI numbers as possible." It is 6+ months since my last note to this board (although I have been lurking on it) and wanted to check in with the board to get feedback. As I said in my note, I don't have a sleep doctor with whom to consult and I get better advise here than anywhere else...and the conviction that it is my therapy, as long as I am armed with the advise of other experienced users, have the ability of improving my therapy on my own. 

thank you for your note, it is always reassuring when you read of others journey... 

talk to you soon,

[DaveL]

Welcome to the forum! My DME tried to tell me that anything under 5 was a cure. Then I (over)reacted.

"If I have to wear all this crap and still try to sleep I want results close to zero." Then I asked if they had ever worn a mask all night with a machine turned on. The answer was no.

people here know so much more about treatment and sleep quality than the few sleep doctors and techs I've had in over 30 years of use.

Others here know so much more than I do.  They'll be able to help.

Good to see your comment. 



If I don't push--HARD--and take responsibility for my treatment, then I might as well have a cpap brick that shows how many hours I've had the cpap on.

After about 35 years of cpap treatment I'm happy to say that the sleep doctor I found is the first to make a change for life quality and healing.

Keys for me...staying current here. Look for other's experiences, and report mine too. And a good DME helps me find a good mask.

[jimcaffey]

Hear Hear David,

Well said then and well said now.

Jim

[Sleeprider]

Jim, I'll try to reply without all the quotes by paraphrasing:

My reference to "next level" means that by eliminating or reducing flow limitation, RERA and hypopnea, you will have fewer arousals that are disruptive to sleep. An arousal is not an awakening, but a change in your sleep stage caused by respiratory effort or distress. Bilevel pressure (EPAP and IPAP) is the most effective means of treating obstructed breathing below the apnea threshold. A higher IPAP assists your inhalation with pressure support, overcoming the airway resistance, and lower EPAP makes exhaling comfortable and effortless. While pressure keeps your airway open, preventing apnea, it is the pressure support that makes breathing more natural and comfortable. When properly applied, you may not be aware of the breath to breath pressure change between inhale and exhale, but it literally melts away airway restriction which is the root cause of arousals and hypopnea. It takes less effort to breathe and you remain better ventilated than without pressure support. Instead of constant higher pressure to pry your airway open, pressure support allows for normalized breathing at lower overall pressure by applying pressure at the right time.

The Philips CPAPs are not bilevel devices. They produce CPAP pressure and only provide up to 2-cm of pressure relief at the beginning of expiration. As you inhale the Philips Flex algorithms anticipates exhale and provides pressure relief to facilitate exhale, but returns to full pressure before exhale is complete. This can leave peak inspiration unsupported and can cut expiration short in some people, and it negates any sense of pressure support that might benefit inspiration. The Resmed CPAP and bilevels cycle to EPAP and do not trigger IPAP until your spontaneous effort triggers the pressure increase. Resmed follows your breathing, Philips anticipates your breathing. In addition, Philips measure inspiratory flow as part of its algorithm, but Resmed actually detects and responds to flow limitation, or inspiratory curve "flattening". This is why Resmed responds ahead of events more effectively, while Philips often waits for a snore, H or OA event to respond with higher pressure. While some people tolerate the Philips algorithms well, there are others that will experience higher levels of RERA and Hypopnea that will not resolve with pressure alone. Those individuals almost always improve on Resmed with EPR or bilevel.

If you zoom into your flow rate to where the inspiratory wave is clearly visible, and scan through the night, every instance of flattening represents a breath that respiratory effort does not result in the smooth flow of air, resulting in more effort being expended, and potentially less air being inhaled. This leads to a recovery breath which is a RERA, or hypopnea, which is a reduction in airflow and potentially desaturation and a physiological response to arouse. Most of these can be resolved by a different machine at lower pressure by using pressure support.