Effort to improve treatment of OSA and IH

[Sleeprider]

Justifying a change in machine is a difficult case, but it really comes down to comfort. If you think the way your Philips APAP applies pressure or, as I see it, results in persistent variable breathing and flow limitation, then you have something to talk about. The Resmed will absolutely be capable of stopping variable breathing from flow limitation, snoring and RERA and will result in a more comfortable, less disrupted sleep. What you're up against is that any supplier is reluctant to take back a used machine, and many of them only distribute Philips under an exclusive sales agreement, and cannot sell Resmed. I frequently see lightly used machines come up on Craigslist, Offerup, Facebook Marketplace and other sales channels that are reasonably priced. I don't know what part of the country you live in, otherwise I'd look.

My preference was for Cflex at 2. The only way to really figure out what works best is some experimentation with the different modes and settings to see what seems best to you. Flex is a comfort feature, so it's not a problem trying out different settings. In my experience, as well as others, Flex setting of 3 can feel disruptive due to sync, or timing problems.

[QuietSign]

Justifying a change in machine is a difficult case, but it really comes down to comfort. If you think the way your Philips APAP applies pressure or, as I see it, results in persistent variable breathing and flow limitation, then you have something to talk about.  The Resmed will absolutely be capable of stopping variable breathing from flow limitation, snoring and RERA and will result in a more comfortable, less disrupted sleep.  What you're up against is that any supplier is reluctant to take back a used machine, and many of them only distribute Philips under an exclusive sales agreement, and cannot sell Resmed. I frequently see lightly used machines come up on Craigslist, Offerup, Facebook Marketplace and other sales channels that are reasonably priced.  I don't know what part of the country you live in, otherwise I'd look.

My preference was for Cflex at 2.  The only way to really figure out what works best is some experimentation with the different modes and settings to see what seems best to you.  Flex is a comfort feature, so it's not a problem trying out different settings.  In my experience, as well as others, Flex setting of 3 can feel disruptive due to sync, or timing problems.

I see. When talking to a doctor, or even for the sake of my own understanding, can I ask what the evidence is that the Resmed can stop variable breathing from Flow limitation, snoring and RERA? Is this known in medical literature that the Resmed is better than the Philips in these areas, or are we extrapolating from people discussing their experiences on these various sleep apnea forums? 

Regarding snoring in particular, are you saying that snoring is tightly linked to/indicative of flow limitations, so the high rate of snoring is indicative of an actionable improvement? Qualitatively, during light sleep phases when I'm just barely conscious, I feel the snoring and it's pretty uncomfortable and borderline distressing. This is especially noticeable during naps.

I'm in SF Bay Area, California. I'm poking around a bit myself and seeing machines for roughly $300-$400, but what do you think I should be paying for a lightly used Resmed APAP? Advice for what to look out for/ red flags? I'm also curious about the other suggestion of the biPAP Resmed Aircurve. Is it worth thinking about if the biPAP would be better, or just stick to APAP for now? Do we think this is indeed a case of UARS?

I just wanted to take a moment to thank you and everyone else on this thread for taking the time to respond to me. I really appreciate your taking time to help me learn.

[Sleeprider]

Those are great questions, and the truth is, Resmed itself is very very quiet about the bilevel capability of its CPAPs, and only refers to EPR as a comfort feature. However this study shows the capability of nine different CPAP machines to normalize breathing on a simulated bench test breathing machine. The Resmed is A and the Respironics is denoted as F on the charts. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5005142/

Feel free to ask any questions you have on this comparative study, but clearly the Resmed exhibits exceptional performance compared to Philips Respironics which fails on nearly every test. For example in Table 1, the Resmed (A1 normal setting, A2 response setting) normalized obstructive apnea while the Philips (F) failed.

We know from practical observation and experience on the forum that the response rate of the Resmed is far superior to Philips for obstruction and hypopnea, and that the machine prevents events that Philips fails to respond to, and it stays ahead of events, while the Philips repeatedly drops pressure below a therapeutic threshold. That is the reason you will so often see us working to titrate the minimum pressure of Philips Dreamstation Auto CPAPs to a level that effectively treats most events.

The sleep medical practice focuses on AHI because that is all that insurance focuses on for coverage. More esoteric issues like flow limitation are ignored, although arousal (RERA), which arises from flow limitation is sometimes considered. The best treatment for flow limitation and RERA is bilevel pressure, where pressure support (the difference in pressure between IPAP and EPAP) supports inspiratory effort with higher pressure support and normalizes breathing. In your case, it is flow limitation that creates variable breathing and frequent arousal or recovery breathing. The problem is your Philips has nothing like pressure support, while the Resmed does, so the only option in your case is to increase pressure. So far, we have not seen where pressure increases resolve the prevailing pattern we see in your charts. Variable breathing is not a clinical condition, but is something your Philips machine uses as a part of the auto CPAP algorithm. You exhibit such a persistent pattern of VB that your machine is no longer functioning as an auto CPAP, but is stuck at one single pressure. If you raise this issue with your doctor, he is going to look at you like you're from another planet, because I don't know of any physician that gets that far into the weeds of how these machines work and interact with patients. I'm simply going to tell you, your results with a Resmed will be unlike anything you have experienced up to now, for the better.

Be safe in buying a used machine and transact business in a public place. Be sure the machine is from a non-smoking household. Even if the user doesn't smoke, that machine will be contaminated by anyone else in the household that does. Ask for the manual and know how to view run-hours on the screen. These are non-resettable and very easy to access after plugging in the machine. Expect to change the tubing, mask and humidifier chamber. These components are inexpensive, and I would not use second-hand.

I am seeing a new in box Resmed S10 Autoset for her for $400 in Pleasanton/Livermore. That is a very good machine at a great price.

[QuietSign]

Those are great questions, and the truth is, Resmed itself is very very quiet about the bilevel capability of its CPAPs, and only refers to EPR as a comfort feature.  However this study shows the capability of nine different CPAP machines to normalize breathing on a simulated bench test breathing machine.  The Resmed is A and the Respironics is denoted as F on the charts.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5005142/  

Feel free to ask any questions you have on this comparative study, but clearly the Resmed exhibits exceptional performance compared to Philips Respironics which fails on nearly every test.  For example in Table 1, the Resmed (A1 normal setting, A2 response setting) normalized obstructive apnea while the Philips (F) failed.

We know from practical observation and experience on the forum that the response rate of the Resmed is far superior to Philips for obstruction and hypopnea, and that the machine prevents events that Philips fails to respond to, and it stays ahead of events, while the Philips repeatedly drops pressure below a therapeutic threshold. That is the reason you will so often see us working to titrate the minimum pressure of Philips Dreamstation Auto CPAPs to a level that effectively treats most events.  

The sleep medical practice focuses on AHI because that is all that insurance focuses on for coverage.  More esoteric issues like flow limitation are ignored, although arousal (RERA), which arises from flow limitation is sometimes considered.  The best treatment for flow limitation and RERA is bilevel pressure, where pressure support (the difference in pressure between IPAP and EPAP) supports inspiratory effort with higher pressure support and normalizes breathing.  In your case, it is flow limitation that creates variable breathing and frequent arousal or recovery breathing. The problem is your Philips has nothing like pressure support, while the Resmed does, so the only option in your case is to increase pressure.  So far, we have not seen where pressure increases resolve the prevailing pattern we see in your charts.  Variable breathing is not a clinical condition, but is something your Philips machine uses as a part of the auto CPAP algorithm. You exhibit such a persistent pattern of VB that your machine is no longer functioning as an auto CPAP, but is stuck at one single pressure.  If you raise this issue with your doctor, he is going to look at you like you're from another planet, because I don't know of any physician that gets that far into the weeds of how these machines work and interact with patients.  I'm simply going to tell you, your results with a Resmed will be unlike anything you have experienced up to now, for the better.

Be safe in buying a  used machine and transact business in a public place.  Be sure the machine is from a non-smoking household. Even if the user doesn't smoke, that machine will be contaminated by anyone else in the household that does.  Ask for the manual and know how to view run-hours on the screen. These are non-resettable and very easy to access after plugging in the machine.  Expect to change the tubing, mask and humidifier chamber. These components are inexpensive, and I would not use second-hand.

I am seeing a new in box Resmed S10 Autoset for her for $400 in Pleasanton/Livermore.  That is a very good machine at a great price.

Thanks, that study certainly goes a long way towards in convincing me that a change in machine is a justified experiment. You say flow limitation creates variable breathing/frequent arousal/recovery breathing - the idea is that these are all problems that result in bad sleep but won't get picked up as part of AHI?

With all this discussion of flow limitation, does this indicate likely UARS at all? Since buying a machine out of pocket is fairly expensive, I'd like to figure out whether the Resmed S10 is the best choice, or if there's a possibility that we should be looking at an Resmed AirCurve biPap.

Regarding the Craigslist listings, to be clear, the Resmed Airsense 10 is the same as the S10, right? The official websites don't use "S10", but all the listings seem to do so. Any opinion on whether the "For Her" version is worth it? I'm a guy, but I did have asthma as a child, and I'm seeing that the For Her offers an extra setting that is said to be helpful for people with asthma, not just women. I also see a new regular Resmed S10 for the same price in San Jose which is closer, so I'm debating whether the For Her is worth it.
Edit: Is there a big year to year difference for these machines? Although they say it is new, I don't know exactly when it was manufactured, so I'm wondering if there are hardware/software differences even within the S10 model.

In the meantime, this is another night's worth of data. I used a Swift FX mask, micropore tape, and the Knightsbridge chin strap. It was a pretty bad night's sleep, and I think the Swift Fx mask is not fitting my nose very well. I elected to try it out since I heard the Airfit P10 has clogging issues with it's mesh that can lead to CO2 rebreathing, which seems concerning.

   

[Gideon]

The ResMed AutoSet are more than adequate for most people for OSA. Without question the ResMed AirCurve 10 VAuto is a more capable machine and is the one we go to for basic OSA when the AutoSet does not meet your needs and you have no underlying medical conditions that would indicate a different model is required.

A common cause of treatment emergent central apnea is the pap device flushes out too much CO2 from the body thus lowering the CO2 concentration to below the apneic threshold resulting in Central Apneas. This is THE major factor in our drive to breathe, not low O2 as many suspect. We have many users on this forum who increase the CO2 rebreathing to eliminate this cause of central apneas. (EERS). So rebreathging a bit of CO2 is not typically an issue, a lot is.

[Sleeprider]

The Resmed machines began with S7, S8 and S9 so the Airsense 10 is often referred to as S10. My guess is that the listing is by someone with a long history of using or selling these machines, and may be a distributor selling out the back-door. It's a good deal, and it is the Airsense 10 Autoset for her.

Your problems with variable breathing are kind of unique, and I would consider it likely that it may be related to UARS. There is no apnea, bt the airway resistance is so persistent that it just does not work with the philips algorithm because you almost never get out of teeh VB mode. I have rarely seen that. I think you need bilevel, and the Vauto would be great, but the one in Pleasanton is a pretty good deal and should deal with most of this issue. You are just a bad match for the Philips Dreamstation, and we can try increasing minimum pressure ans see where that takes us, but I think we eventually end up trying to get a better machine for you that actually mitigates the problem, rather than tries to hammer it into submission.

[QuietSign]

The ResMed AutoSet are more than adequate for most people for OSA.  Without question the ResMed AirCurve 10 VAuto is a more capable machine and is the one we go to for basic OSA when the AutoSet does not meet your needs and you have no underlying medical conditions that would indicate a different model is required.

A common cause of treatment emergent central apnea is the pap device flushes out too much CO2 from the body thus lowering the CO2 concentration to below the apneic threshold resulting in Central Apneas.  This is THE major factor in our drive to breathe, not low O2 as many suspect.  We have many users on this forum who increase the CO2 rebreathing to eliminate this cause of central apneas. (EERS).  So rebreathging a bit of CO2 is not typically an issue, a lot is.

The Resmed machines began with S7, S8 and S9 so the Airsense 10 is often referred to as S10.  My guess is that the listing is by someone with a long history of using or selling these machines, and may be a distributor selling out the back-door.  It's a good deal, and it is the Airsense 10 Autoset for her.

Your problems with variable breathing are kind of unique, and I would consider it likely that it may be related to UARS.  There is no apnea, bt the airway resistance is so persistent that it just does not work with the philips algorithm because you almost never get out of teeh VB mode.  I have rarely seen that.  I think you need bilevel, and the Vauto would be great, but the one in Pleasanton is a pretty good deal and should deal with most of this issue.  You are just a bad match for the Philips Dreamstation, and we can try increasing minimum pressure ans see where that takes us, but I think we eventually end up trying to get a better machine for you that actually mitigates the problem, rather than tries to hammer it into submission.

So my case is a bad match for the Dreamstation? I overall have seen very little improvement since starting on it, and I'm wondering if it's because my AHI was never that high in the first place and my issues were resulting from the more subtle stuff...

Regarding the bilevel, there is a used ResMed AirCurve 10 ASV BiLevel Machine in Sacremento for $640. How much of an difference do you think it would make compared to the Airsense 10 autoset? Is the difference in price worth it?

[Gideon]

You can consider a 2 step process if you like.

1. get a used low hour ResMed AutoSet, you should be able to resell it for something close to what you paid for it.
2. if the AutoSet doesn't cut it, resell it and buy a ResMed VAuto.

No matter your choice we will help you to source it, but ultimately it is your choice.

I have a VAuto. I will not use anything else unless my condition requires it.

Is the difference in price worth it? Entirely your call. Consider that 1/3 of your life, more or less, is spent sleeping.

[QuietSign]

You can consider a 2 step process if you like.

1. get a used low hour ResMed AutoSet, you should be able to resell it for something close to what you paid for it.
2. if the AutoSet doesn't cut it, resell it and buy a ResMed VAuto.

No matter your choice we will help you to source it, but ultimately it is your choice.

I have a VAuto.  I will not use anything else unless my condition requires it.  

Is the difference in price worth it? Entirely your call. Consider that 1/3 of your life, more or less, is spent sleeping.

Oh, hang on. I think I'm looking at the wrong model for the bipap. Turns out it's not a VAuto, but rather an ASV for central apneas. It seems an actual VAuto costs roughly $1000 used.

In this case I think the Resmed S10 Autoset makes more sense to try at first, like you described. I'm trying to decide between the regular S10 vs the S10 for her. Is the For Her setting useful? I'm trying to negotiate the price a little bit, so I'd like to get a sense of what this feature is worth.

[Gideon]

The list price of the AutoSet and the AutoSet for Her is the same.  Sometimes at lower pressure the 'For Her version can be somewhat beneficial.

The key thing below is the different BiLevels are NOT interchangeable.

The Auto CPAP such as the AirSense 10 AutoSet is typically the initial machine of choice for treatment of obstructive apnea and hypopnea
Just to clarify The VAUTO, ASV, S, and the ST are all BiLevel machines for treating three different conditions, they are NOT interchangeable. They are not a choice between them to treat a single condition.
They should be chosen to treat the specific condition that the user has, Here are the various CPAP machines and what they are designed/intended to treat
This info is from the ResMed Sleep Lab Titration Guide

• CPAP (continuous positive airway pressure) Fixed pressure delivered with optional expiratory pressure relief (EPR). It Treats OSA
  

• AutoSet/APAP (automatic positive airway pressure) Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas. It treats OSA
  

• AutoSet for Her/APAP Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas along with an increased sensitivity to each flow-limited breath, providing a more comfortable therapy for women. Increases sensitivity to each flow-limited breath, providing a more comfortable therapy for women (OK for men too). It Treats OSA
  

• VAuto Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas; Pressure Support (PS) is fixed throughout the night and can be set by the clinician. It Treats OSA, non-compliant OSA
  

• S (Spontaneous) Senses when the patient is inhaling and exhaling, and supplies appropriate pressures accordingly. Both treatment pressures are preset: inspiration (IPAP) and expiration (EPAP). It treats Non-compliant OSA and COPD
  

• ST (Spontaneous/Timed) Augments any breaths initiated by the patient, but also supplies additional breaths if the breath rate falls below the clinician’s set “backup” respiratory rate. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions
  

• T (Timed) Supplies a clinician-set respiratory rate and inspiratory/expiratory time, regardless of patient effort. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions
  

• iVAPS (intelligent Volume-Assured Pressure Support) Maintains a preset target alveolar minute ventilation by monitoring delivered ventilation, adjusting the pressure support and automatically providing an intelligent backup breath. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions
  

• ASV (adaptive servo-ventilation) Targets the patient’s minute ventilation, continually learning the patient’s breathing pattern and instantly responding to any changes. It treats Central or mixed apneas, complex sleep apnea, Periodic Breathing (PB)
  

• ASVAuto Provides an ASV algorithm plus expiratory positive airway pressure (EPAP) that automatically responds on the patient’s next breath to flow limitation, snore and obstructive sleep apneas. It Treats Central or mixed apneas, complex sleep apnea, Periodic Breathing (PB)
  

• PAC (Pressure Assist Control, also known as Pressure Control) The inspiration time is preset in the PAC mode; there is no spontaneous/flow cycling. Inspiration can be triggered by the patient when respiratory rate is above a preset value, or delivered at a set time at the backup rate. It Treats Neuromuscular disease (NMD), pediatric patients