Finally, SUCCESS after almost giving up on CPAP (retitled)

[Computerdoc]

So Bonjour was referring to something he saw in the charts?

Hopefully these are what you're looking for.

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[Sleeprider]

That is exactly what was needed.  Let's discuss.

In this example at 00:44 we see the pink shading of the variable breathing, and immediately see the flow rate is fluctuating.  In this case, we know it is obstructive because we can see the flattened inspiratory wave at 00:4:50 leading into an arousal and larger amplitude breathing. This is the definition of a Respiratory Effort Related Arousal (RERA).  The arousal is followed by more shallow breathing as your previous recovery breathing flushed the CO2 from your system and your respiration is a bit suppressed.  The variable breathing continues in a cycle but is not very remarkable for obstruction or flow limitation.



The screenshot at 06:10 where you clearly had a lower respiration rate is exactly what I said it would be.  Squashed flat inspiratory flow waves that show a very serious flow limitation.  This may even be an airway restriction related to your sleep position where you tuck your chin.  This kind of airway resistance is very difficult on your sleep and will cause oxygen desaturation on nearly the same order as apnea.  You can see the inspiratory wave above the red line is very flow limited and your breathing resembles a kid trying to drink a thick shake through a thin straw.  This is a lot of work and thus we know it is going to end with a Respiratory Effort Related Arousal (RERA).  The machine is responding with a pressure increase here, but it is very slow to rise.  A Resmed would have been all over this and raised pressure significantly.  This might resolve by either avoiding the positional airway restriction using a soft cervical collar, or higher pressure or pressure support to replace your respiratory effort with a mechanical boost from the machine.  Unfortunately that boost of pressure support requires a bilevel, and you ain't got one.  That leaves us with considering ways to avoid positional airway restriction, or considering an increase in pressure. 

The inhale and exhale pressure is very close here. I assume Flex is off, and you might want to use Cflex or Aflex at a setting of 1 or 2 to provide some pressure relief during expiration. Flex settings are for comfort not therapy, and the best way to choose a setting is just to try them and see what feels right.

[Computerdoc]

Wow, so much great information!

I’m going to get a Resmed ordered today.  You mentioned that a Bilevel would resolve some of my difficulties.  Would you still recommend the Airsense or would the Aircurve be a better choice?  My sleep doctor’s office said they’d send a prescription to my choice of vendors.

[staceyburke]

I think the Resmed 10s VAITO is the best machine IF you can get it without paying a lot more. It gives you a lot more options for therapy but insurance does not want to pay more than they have to.

[Computerdoc]

I’d like to get some opinions about whether the Resmed S9 bilevel or the S10 aircurve vauto would be better for my needs.  I spoke with a vendor at #2 who said the main differences were wireless capability and slightly improved algorithm on the S10, compared to much greater service life on the S9.  Either purchase would be gently used, not new.

Or would the Airsense S10 do the trick? I could go new (self pay) on that model.

[staceyburke]

I have not had any experience with the s9 but have only heard good 10s Airsense. The airsense seems to allow almost bilevel capability.

[Sleeprider]

Basically the same machine in a different form factor. Anything we can do with the Vauto can be done with the S9 VPAP auto. The main inconvenience is with the S9 you must remember to lock the SD card before inserting in the computer and unlock it before putting it back into the S9. The S10 is more compact for travel.

The Airsense 20 is a very good responsive machine. The main difference is pressure support is limited to 3 cm.

[Computerdoc]

Basically the same machine in a different form factor. Anything we can do with the Vauto can be done with the S9 VPAP auto. The main inconvenience is with the S9 you must remember to lock the SD card before inserting in the computer and unlock it before putting it back into the S9. The S10 is more compact for travel.

The Airsense 20 is a very good responsive machine. The main difference is pressure support is limited to 3 cm.

In view of my last Oscar report that you analyzed, you refer to a “boost of pressure support that requires a bi-level.”  Would the Airsense 10 with its 3 cm pressure support limitation been up to the task in that situation, or would that require a full bi-level machine?

[Sleeprider]

Great question. You're currently using a Philips Dreamstation that has nothing to offer in that respect. We have seen flow limitation respond positively to the Airsense 3 cm EPR and examples can be found in the Flow Limitation wiki. Frankly, we were surprised to learn that a CPAP can have enough bilevel capability to make a difference. We have frequently treated flow limitation, RERA and hypopnea with the Airsense 10 series with good success. The problem is, when you run out of room for pressure support, you are out of options and have to go back to pressure increases. I can absolutely promise the Airsense 10 would move your therapy to a new level, but a VPAP or Vauto has a few more tricks up its sleeve. You really don't nee any fancy changes to the inspiration timing or sensitivity those machines also provide, but it's there, as well as fine-tuning of pressure support in 0.2 cm increments rather than 1, 2 or 3 cm.

[Gideon]

I'll add that we tried to utilizePR's flex in the same manner, seems logical, but we see nowhere near the same impact, with a typical impact of zero, though Flex reduction often helps with a central apnea reduction. Realize that EPR and Flex are not supposed to have an impact on central apnea.