Best Machine to deal with high Flow Limitations

[palerider]

ASV. ASV ASV ASV ASV ASV .

an ASV is for treating *central* apneas, not flow limitations.

now, a vauto could help, since it's got more pressure support than EPR gives you.

[Pugsy]

Ahhh...I see said the blind man.

Just how bad are your flow limitations currently on your S9? Screen shot please?

Here's the deal...I have used both the S9 VPAP Auto and the S9 Adapt (which is of course the equivalent of the AirCurve 10 ASV) and when going by just the FL graphs...the Adapt FL graph looks horrible compared to the VPAP FL graph and I am not the only one who noticed this.
And I have never had any particular issues with Flow Limitations and neither had the others who went to ASV and said "what the hell....my FLs are crazy bad"...
Now I don't think my FLs suddenly got bad but the damn graph made them sure look bad. I finally just turned them off because I knew they weren't really that bad. Nothing I did made them look any better and same with the others that were in the same boat.

It's going to be hard to meet criteria to justify ASV unless you have some centrals going on.

Sounds more like you need a machine that can go higher than 20...and that would be a bilevel and without criteria to earn the ASV bilevel just a regular bilevel which is pretty much nothing more than the AutoSet but will go to 25.
So goes higher than 20 plus gives room for additional Pressure Support beyond the 3 cm max that EPR offers.

[StuUnderPressure]

ASV. ASV ASV ASV ASV ASV .

an ASV is for treating *central* apneas, not flow limitations.

now, a vauto could help, since it's got more pressure support than EPR gives you.

SORRY - I did mean the ResMed AirCurve 10 VAuto & not the ResMed AirCurve 10 ASV.
And, after I entered it wrong the 1st time, I just kept recopying it from that.

See what Sleep Deprivation will do to you !

[Pugsy]

Crap. Disregard all that ASV stuff.

[Jay Aitchsee]

Stu, why don't you post some sleep examples, either ResScan or Sleepyhead, so we can have a look at what's going on?

I think the S9 auto will treat Flow Limitations as well as the AirSense 10 Autoset or the For Her Model - basically the same machines with the exception of the added algorithm of the For Her model.

Based on what you've told us so far, I would vote with the others for the Aircurve 10Vauto (essentially the same as the S9Vpap auto).

As PR noted, Flow Limitations are treated with more pressure. As Pugsy said, a bilevel would allow higher IPAP with Pressure support and a lower EPAP combination than you could obtain with your S9 (or the Airsense 10) and EPR.

You might also try reducing your Flow limitations with a soft cervical collar like one of these https://www.amazon.com/s/ref=nb_sb_ss_i ... N5DU1QZKT6 Keeping the chin up will tend to keep the airway open. Also, I think I mentioned earlier that I experienced a reduction in Flow Limitation after switching to nasal pillows.

All of that said, you may find that simply limiting your max pressure such that Flow Limitations detected won't drive the pressure above that needed to prevent hypopneas and obstructive apneas might work for you.

It depends to some degree as to whether or not Flow Limitations are disturbing your sleep. It seems that some find them disturbing and some do not. ResMed treats them, I believe, primarily as method to prevent hypopneas and apneas - as Flow Limitations are seen as a precursor. So by treating them, obstructive events can be prevented. Now it is possible to experience Flow Limitations which do not develop into full blown obstructive events, and some have found the treatment (rise in pressure) to be more disturbing than the Limitations. These people often opt for a fixed pressure or a narrow auto setting.

Possibly a sleep study, a polysomnogram, could help you sort this out.

[StuUnderPressure]

Stu, why don't you post some sleep examples, either ResScan or Sleepyhead, so we can have a look at what's going on?

Looking for some older ResMed Graphs (prior to switching on the EPR) to post.

Will also post some graphs post EPR

Problem is I replaced my Desktop PC in between & did not put the older graphs on the new PC.
And, the old PC is all but stone dead - so hard to retrieve.

But, I am working on it.

[StuUnderPressure]

Because of a bad back, I sleep in a recliner for most of the night.
Then, I go into a bed for the last couple / few hours when I can no longer stand the recliner.
I have a separate ResMed S9 AutoSet at the recliner and a 2nd ResMed S9 AutoSet at the bed.

APAP pressure settings on both S9 AutoSets are 13 - 20 with EPR 3

The following graphs are for last night 6-22-17

I am afraid my old data (pre EPR) is lost forever.
However, those graphs merely showed the FLs to be much worse (i.e. the FLs graphs would often make it all the way to the top of each graph)

http://imgur.com/xA4o4dT
http://imgur.com/03n9W3x
http://imgur.com/xuSMRpQ
http://imgur.com/U9y0sls

[StuUnderPressure]

You might also try reducing your Flow limitations with a soft cervical collar like one of these https://www.amazon.com/s/ref=nb_sb_ss_i ... N5DU1QZKT6 Keeping the chin up will tend to keep the airway open. Also, I think I mentioned earlier that I experienced a reduction in Flow Limitation after switching to nasal pillows.

I do already have a soft cervical collar that I tried a while back to try to get rid of my chin strap.
Was not successful.
Will see if it has any effect on FLs

I have also tried several nasal pillows masks.
I just cannot get them to seal well enough.

It depends to some degree as to whether or not Flow Limitations are disturbing your sleep. It seems that some find them disturbing and some do not. ResMed treats them, I believe, primarily as method to prevent hypopneas and apneas - as Flow Limitations are seen as a precursor. So by treating them, obstructive events can be prevented. Now it is possible to experience Flow Limitations which do not develop into full blown obstructive events, and some have found the treatment (rise in pressure) to be more disturbing than the Limitations. These people often opt for a fixed pressure or a narrow auto setting.

I am not bothered by any rise in pressure.
Am also used to a higher pressure I had on a previous straight CPAP brick.

But, the FLs do seem to negatively affect how I feel when I wake up in the morning.

Possibly a sleep study, a polysomnogram, could help you sort this out.

I believe my Sleep Doctor and the related hospital that does the Sleep Studies is by far better than most out there.
But, from my discussions with the Sleep Doctor, they know even less (MUCH LESS) than my elementary understanding of FLs & how to control them.

[Jay Aitchsee]

Stu, In isolation your graphs don't tell us much. But certainly you seem to have hypopnea and apnea under control, based on the statistics.

It would be better to show the Flow Limitations in relation to the other data as I have in the example below. Multiple graphs can be shown in the Navigation Window such as these, or close ups can be show in the Detailed Data window on the bottom. (These graphics could have been much larger, but I was in a hurry

Next we need to know the scale of the Flow Limitation Graph. Notice my Flow Limitations in the two examples below. They are the same graph but different scale. Unfortunately, the graphic doesn't readily indicate the scale.

To check and set the scale. Go to Tools>Options to get the dialogue box shown in my example. To put your Flow limitations in perspective make sure the "upper" is set at 1.0 for now, as it is for the top chart of my example.

I believe my Sleep Doctor and the related hospital that does the Sleep Studies is by far better than most out there.But, from my discussions with the Sleep Doctor, they know even less (MUCH LESS) than my elementary understanding of FLs & how to control them.

But at the lab, they may be able to determine your RDI which would include arousals (if any) from Flow LImitations, or RERAs. See the AASM Manual Rules, sec 4.3.


Edit:
I believe each line of the Flow Limitation Graphic represents 0.05 regardless of scale. If so, I'm guessing your "upper" setting is around 0.5. I believe the default is 1.0. If it was changed from the default of 1.0 to 0.5, it would make your Flow Limitations "look" worse because of the scale and could account for a seeming change.

However, assuming the lines represent 0.05, you have many instances that far exceed that. It appears from my study that ResMed will raise the pressure of an auto machine when a Flow Limitation of 0.05 is encountered. From this, it would seem one would want to keep the "average" of Flow Limitations below 0.05. Keep in mind, this is just my conjecture based on my observance of how the machine responds. Aside from the mechanical means I mentioned above, the only way I know to lower the Flow Limitations would be through the application of additional pressure. This pressure may far exceed what would be needed to eliminate apneas and hypopneas. This is where a bi-level could be useful. At some point, additional EPAP could be disturbing to exhale against. A bi-level would allow higher IPAPs without raising EPAP so much through the use of Pressure Support (PS), essentially the difference between IPAP and EPAP. EPR is similar to PS, but it is limited to 3.0. With a bi-level, such as the Aircurve Vauto, that difference could be increased beyond the limitation of the 3.0 of the S9 auto and the Airsense 10.

After you check your setting, we will have an idea of your Flow Limitation magnitude. BTW, if you hold your cursor over a point of the Flow Limitation graphic, the value of the point will display as a pop up.

Your graphic showing 9:30 - 01:30:

[StuUnderPressure]

Here is the screenshot for 6-22-17 Recliner All Data

The Upper Setting for the Flow Limitations was at 0.5 for the previous FLs graphs
I changed it to 1.0 before I posted the graph below of all of the data for 6-22-17

http://imgur.com/2jnwAgt

[Guest]

do you really want THAT gone? (we are really talking about that very low - nearly flatlined FL-chart on the bottom?)

pressure up a bit more - should be done!

I really have my doubts that a BIPAP could improve your flow-curve even more, as it is already nearly perfect.
If you have doubts you could zoom in on the flow-chart on your "highest" flowlimitation - so that we can look at the actual breathing form.

[Jay Aitchsee]

Stu, I think I have to agree with Guest. Your charts look nearly perfect. You are experiencing some Flow Limitations, but they are not terrible. You could turn on the Flow graph and get rid of a couple others leaving Minute Vent, Pressure, Leak, Events, Flow Limitations, and Flow which might give us a little better over all look.

You might want to try SleepyHead. It will yield more info on Flow Limitations to include min, max, average, etc.

I'm not sure why you think Flow Limitations are disturbing your sleep. Are you sure it's not pain, or something else, like sleeping in the recliner for part of the night? I don't see any evidence that your sleep is disturbed, like a bunch of CAs, though your Flow chart could be revealing. Do you sense that your sleep is disturbed? You referred to feeling tired in the presence of Flow Limitations. How did you determine that? Are they not there at times? ResScan really doesn't provide a measure to compare the intensity of Flow Limitations from night to night (SleepyHead does).

You could try opening up the max some and see if the machine will drive the Flow Limitations down further and see if you feel better. I kind of doubt that you will, but it worth a shot. Right now it looks like the Flow Limitations are driving the pressure to a max limited to about 13 or 15 or so. You could set the max at 20 and see what happens.

The only way I know to tell for sure if your sleep is being disturbed by respiratory events it with a PSG.

[squid13]

If you set the machine to 20 it will only go as high as it needs to go. Just because it's set to 20 doesn't mean it will go there. I agree with Jay, set it to 20 and lets see what happens.

[StuUnderPressure]

APAP pressure settings on both S9 AutoSets are 13 - 20 with EPR 3

My upper level is already at the Max 20

[Guest]

I meant: raise the lower level a bit!

I would NOT advise that - the higher the pressure the lower air is available to oxygenation.

your flowlimits are NEAR PERFECT - really!