Ready to go postal

[tvmangum]

I have had it! I'm ready to fire my sleep doctor and my DME (Apria) especially after today.

Last month I did a 5 day at home titration with a ResMed APAP AutoSet II. The pressure was set to go from 5 to 20 even though my normal pressure is 14. Long story short . . . my AHI was all over the place from 10 to 20+. I called the RT at the DME and was basically told to ignore it which I did. If I remember correctly, the highest pressure on the APAP was in the 8-9 range.

Approx 3 weeks ago I turned my pressure up to 15 on my own and my AHI started coming down. My AI was from 0.5 to 1.9 with my HI still being in the 7 to 9 range. I contacted the sleep doctor and I now am scheduled for another night at the clinic. Wednesday I got a call telling me that the sleep doc wanted me to do one month on the APAP again and the clinical titration. Ok no problem.

Go to get the APAP today and guess what . . . the range once again is set for 5 to 20. I told them that it was too wide a range and the APAP would not be able to keep up with the changes in my breathing and that the pressure should be set to start at 12 (just like I have read here several times.) The RT told me the ResMed machine would respond within 3 breaths. I then asked if it was at 5 how long would it take to get to where it needed (ie. CSA) to be and she responded that the machine would slowly start getting to the correct pressure. I kept saying that it was not right because it could not keep up with me and are we sure that this would work. In other words, trust the machine and the doctor that I have never met. I kept pressing my point and was nice but firm in that this did not work before and probably would not work again. BIG MISTAKE.

The RT got the supervisor and she came in and basically told me that I could either (1) get another sleep study--which is scheduled for 3 weeks, (2) refuse the machine and talk with the sleep doc on Monday or (3) just take the machine. By that time I was so PO'd that I told them that I had been dealing with this for 6 months and was ready to get to feeling better. I signed the paperwork and left with the machine.

I am so aggrivated that I don't know what to do. Suggestions???

[AuntieNae]

If it were me, I would set the pressure to what I know was working for me. But, that is me ..

[roster]

I spent two nights in two different sleep labs and neither could get anywhere near the correct pressure.

Titrated at home with my own machine over maybe two weeks and found the sweet spot that keeps AHI < 1.0.

I betcha there are hundreds of thousands of patients using suboptimal pressures that the labs prescribed.

I believe in self-titrating in your own bed over several nights. A good starting point for the pressure is what the lab prescribed. But it is only a starting point and if it turns out to be optimal, it was just by luck.

What's the deal on your insurance? How much are you having to pay out of pocket for the machine and the sleep studies?

[carbonman]

I got a call telling me that the sleep doc wanted me to do one month on the APAP again and the clinical titration. Ok no problem.

....man, you pay off like a loose slot machine. They're going keep you around.

I am so aggrivated that I don't know what to do. Suggestions???

Become your own best therapist.

I am.

[GumbyCT]

I have had it! I'm ready to fire my sleep doctor and my DME (Apria) especially after today.

Last month I did a 5 day at home titration with a ResMed APAP AutoSet II. The pressure was set to go from 5 to 20 even though my normal pressure is 14. Long story short . . . my AHI was all over the place from 10 to 20+. I called the RT at the DME and was basically told to ignore it which I did. If I remember correctly, the highest pressure on the APAP was in the 8-9 range.

Approx 3 weeks ago I turned my pressure up to 15 on my own and my AHI started coming down. My AI was from 0.5 to 1.9 with my HI still being in the 7 to 9 range.

Don't know if you've read the recent thread here saying that Resmeds don't respond to apneas when over 10cm? Your findings seem to show this as being true.

If it were me, I would set the pressure to what I know was working for me. But, that is me ..

I 2nd this approach.

....man, you pay off like a loose slot machine. They're going keep you around.

- does this mean you are made of money? Do you need the rape test kit? How do you feel?

[Diehart]

I get nothing but aggravation from these so called experts too. I lot of money is being made on us and our health just is not their priority. It really makes me sick!

[Wulfman]

You're quite likely dealing with some money-grubbing idiots. I'd take my prescription and walk (actually run) away.
You've got an idea of the vicinity of where your pressure needs to be. That ResMed Auto won't do the job because of its A10 algorithm. If you've already got the Elite II, you should be able to fine-tune it.


Den

[rested gal]

Well, this might be a good opportunity to educate a doctor. That is, if the doctor is open to learning new things from a "patient." Doesn't sound like the RT likes hearing the patient question whether 5 - 20 is a good idea, but the doctor might be interested in what you have been learning and what you show him might help other people for whom he orders autotitration trial in the future.

I'd try to get the Monday appointment to talk with the doctor. In the meantime, I'd use the autopap at both ranges...each for a couple of nights during the 4 night trial... doesn't matter which order ... 5 - 20 for a couple of nights; 12 - 20 for a couple of nights. Get the DME to print out the full report. Hopefully the doctor will be able to see for himself the difference in results at those two settings. Then you could discuss with him how autopaps are designed to raise pressure slowly and why starting wayyyyy low for someone who normally needs considerably higher pressure might not be a good idea.

If the doctor gets angry that you chose to undertake your own carefully considered experiment for two nights out of the four, he's not a doctor I'd want to deal with any further anyway. He might surprise you, though, by being impressed and in agreement with what you do. If you decide to do it. Could be a fun experiment to do, revealing the doctor's personality.

Me...I'm comfortable with monitoring my own results and tweaking my own pressure, so I'd personally walk away and take care of handling my own treatment -- without the doctor. With the Elite II, I wouldn't even bother to get the software. I'd just look at the efficacy results in the machine's window. And I'd mentally cut the hypopnea number in half. That's just me. But I'm no doctor.

[preemiern]

The RT told me the ResMed machine would respond within 3 breaths.

But if you are apneic, you are not having breaths, so how would the machine respond within three breaths...or three "non-breaths" rather.

[lktnky]

Help please in locating the thread about Resmeds not working above a pressure of 10? Quoted by Gumby?

[cflame1]

Try this
viewtopic.php?f=1&t=40801&st=0&sk=t&sd=a&hilit=A10

[GumbyCT]

May I ask - what is the reason for the in home titration? And then the reason to re-re-repeat it?

[rested gal]

Don't know if you've read the recent thread here saying that Resmeds don't respond to apneas when over 10cm? Your findings seem to show this as being true.

Gumby is correct about ResMed machines not increasing pressure over 10 cm when presented with an apnea.

-SWS, ozij, and Velbor explained more about that in the topic cflame1 provided a link for. The topic was started by bangy104 and was called:
Comparison Resmed S8 AutoSet II vs Remstar M Series
viewtopic.php?p=357206#p357206

lktnky, don't let the statement (even though it is a true statement) that "ResMed autopaps don't respond to apneas over 10 cms" make you think that means ResMed autopaps can't or won't treat a person's Obstructive Sleep Apnea just as well as any other autopap does.

That true statement about ResMed's A10 algorithm -- not increasing pressure for an apnea if the machine is already using a pressure of 10 or more -- should be considered in light of what the machine is designed to do. It's designed to prevent apneas from happening by responding to flow limitations (partial collapses of the airway) and snores (which are often precursors to the beginnings of a collapse.

A ResMed machine will respond with more pressure than 10 cm to try to eliminate flow limitations and snores. The machine is designed to attempt to PREVENT apneas from happening by treating flow limitations with pressure all the way up to whatever the maximum pressure in the range is set for. Could be as much as 20 cm.

All autopaps (not just ResMed) are designed to be careful in their own way -- with their own unique design algorithms -- to not just slam more and more pressure at any random apnea that happens to sneak through. The main job every autopap attempts to do when it increases pressure is to treat flow limitations (the beginning of throat collapse and partial collapses) effectively BEFORE the partial collapse gets worse and becomes closed enough to be an apnea. Despite all efforts to prevent flow limitations from becoming worse, an apnea can still occur -- either suddenly, or by developing too fast for the machine to respond to the worsening collapse.

Faced with an apnea situation, all autopaps, if they could talk, might say... "Whoops, there's no airflow, or so little that it might as well be none. Must be an apnea. But... which kind of apnea is it? Is it an obstructive apnea? If so more pressure might help. But... if it's a central apnea, the throat is already open. More pressure won't help a bit, because, well... because the throat is already open. Hmmm, what to do now?" And that's one of many ways where each autopap's manufacturer's design is different. What do you do if you're not sure whether an apnea is an obstructive (airway closed) or is actually a central (airway open)?

-SWS and ozij can explain best how each autopap manufacturer has its own design to guard against unnecessary jumps in pressure in case an apnea might be a central rather than an obstructive.

Bottom line... ResMed's A10 algorithm to NOT raise pressure above 10 cm for an apnea (if the machine is already using 10 cms or more) does not mean the machine will not raise pressure as much as needed to correct flow limitations and snores. It will treat people at pressures above 10 cm as needed, to correct those things. What it won't do is hammer more pressure above 10 cm if a sudden apnea occurs. It will wait that one out. And that's a very good safety guard that provides good treatment for most people, most of the time.

The problem that any autopap has with preventing apneas most effectively, imho, is the minimum pressure setting that most doctors order, or leave up to the DME to set. Most order a minimum pressure of 4 or 5, which is usually not anywhere near enough to provide effective treatment for most people. I think it is that too-low-minimum-pressure that contributes to letting too many apneas sneak through while the autopap goes about its job the way autopaps are supposed to... slowly and gradually raising pressure (even above 10 when need be) when flow limitations or snores are sensed. Correcting those partial collapses with more pressure, to try to prevent further collapse of the airway into an apnea.

Autopaps are not supposed to yo-yo pressure up and down suddenly, which could be very disruptive to sleep. Their job is to prevent the kind of worsening airway collapse that often would result in an apnea. They can do that preventative job well, but only if the minimum pressure is set high enough in the first place to allow them go about their job efficiently and effectively. If an apnea sneaks through suddenly, each brand of autopap has its own design for "what to do then."

[lktnky (guest)]

THANKS RG!

How can I tell if I snore?
I download the night's data every morning, but only use the data card and do not want to buy ResLink.
Can I tell if I snore just by looking at the data?

[plr66]

That true statement about ResMed's A10 algorithm -- not increasing pressure for an apnea if the machine is already using a pressure of 10 or more -- should be considered in light of what the machine is designed to do. It's designed to prevent apneas from happening by responding to flow limitations (partial collapses of the airway) and snores (which are often precursors to the beginnings of a collapse.

A ResMed machine will respond with more pressure than 10 cm to try to eliminate flow limitations and snores. The machine is designed to attempt to PREVENT apneas from happening by treating flow limitations with pressure all the way up to whatever the maximum pressure in the range is set for. Could be as much as 20 cm.

Laura, thanks for such a clearly written explanation. For whatever reasons, I just could not follow the argument in the earlier thread "Comparison Resmed S8 AutoSet II vs Remstar M Series" (viewtopic.php?p=357206#p357206)--but now it all seems so clear!