Went to my sleep specialist today - haven't seen him since before going on cpap in mid 2005. Here is a frank and honest report on the meeting that took place & some of the matters discussed. Contained a few surprises for me
In his hello he read the summary from my sleep study saying "and your titration recommendation was 13".
WHAT says I, I was told 15!. In fact I phoned the sleep clinic back when setting up my machine to ask if the handwritten note stating the titration cms was a 13 or a 15 as it was not easy to read. The clinic came back with 15. So for over 18months (until I recently lowered the cms to 13 based on my own home study) I had been running the machines at 15 as the main cms setting.
The difference between 14 and 15 for me is that it has always been the threshold for mask leaks - and all the other extra surprises we get when we go to higher cms settings (aerophagia etc:)..
The other point that this sleep specialist made during discussions & going over the results of some of the testing I had done, was that the titration of 13 IS THE MINIMUM cms they recommend for cpap for me. It is the number at which I am likely to have events if my pressure is set below that number.
He pointed out that me setting my epap to 8 was too low and that was why the bad results had shown up with the bilevel set to 8/15. He stated again that the titration number was in effect the epap!. It is the threshold at which AI & HI events are best contained!.
He has requested another sleep study (routine & free to us here in Aust) for feb next year & has said that he wants to do it as a split study partly with my fav UMFF mask & partly with my fav nasal pillows (an Adams Circuit mask).
He said it was a known fact backed up by published reports (covering the deadspace issue) that almost every mask is going to change the ideal titration and that nasal pillows masks typically require a slightly lower cms setting (depending on the actual model).
We got to discussing Resmed's price hike & he said didn't you know they just built a massive new factory ?. They have to pay for it somehow"
His comments on the issue of Autos vs Cpaps was
"Autos provide you with unneeded Bells & Whistles! - go buy yourself a Remstar Pro with a smartcard - thats all anyone on straight cpap therapy needs!" (I told him I already had 1 (or 2 (or ? ))) - "That one is all you need" says he!. When pressed, he said that in his profession, they were not happy about the auto algorithms that the manufacturers won't disclose. He said they claim they are proprietary but he considers that so much b*lls**t !" -- (very outspoken Dr this one ).
I mentioned what I had read about of the Adaptive Servo Ventilation machines. His comment was that has been around in principle for a while & known as PAV (Positive Airway Ventilation). He said that from his perspective there was no evidence that all the extra technology made any difference for the normal cpap user. A straight CPAP was still the best and most effective solution & that unless someone had a specific need for such a machine it was more than what is needed. He agreed that recording nightly data was very valuable for all concerned.
He appreciated the data I had gathered & when I mentioned it was on the Internet he asked if I had any details on the numbers of 'hits' to the data. He said he believed it would get a lot of interest & asked me to track it.
DSM
Surprise surprise !
Surprise surprise !
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
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birdshell
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What a doc! He is perfect, except for one thing:
If he had said, "Just a minute--I want to look something up." Then, IMO, he would have been perfect. Of course, maybe he would, but had no need with you.
When docs are honest, and treat the patient as if s/he were actually sentient, PLUS they are not too egotistical--that is when good treatment seems to happen, IMHO.
Oh, yes, just one more problem: Australia is something like 22 hours away by plane....
Good on ya! And, good on 'im.
If he had said, "Just a minute--I want to look something up." Then, IMO, he would have been perfect. Of course, maybe he would, but had no need with you.
When docs are honest, and treat the patient as if s/he were actually sentient, PLUS they are not too egotistical--that is when good treatment seems to happen, IMHO.
Oh, yes, just one more problem: Australia is something like 22 hours away by plane....
Good on ya! And, good on 'im.
Be kinder than necessary; everyone you meet is fighting some kind of battle.
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MD Feedback
dsm
It's good that he straightened out the 13 versus 15, even if you had identified it on your own. Great validation.
I have not heard of Positive Airway Ventilation, but I do find it interesting that both ResMed and Respironics both call it Adaptive Servo Ventilation, which implies that neither own the IP rights to the term.
Take care
Lubman
It's good that he straightened out the 13 versus 15, even if you had identified it on your own. Great validation.
I have not heard of Positive Airway Ventilation, but I do find it interesting that both ResMed and Respironics both call it Adaptive Servo Ventilation, which implies that neither own the IP rights to the term.
Take care
Lubman
birdshell wrote:What a doc! He is perfect, except for one thing:
If he had said, "Just a minute--I want to look something up." Then, IMO, he would have been perfect. Of course, maybe he would, but had no need with you.
When docs are honest, and treat the patient as if s/he were actually sentient, PLUS they are not too egotistical--that is when good treatment seems to happen, IMHO.
Oh, yes, just one more problem: Australia is something like 22 hours away by plane....
Good on ya! And, good on 'im.
Well actually he did He went to his computer & extracted a copy of a report called ...
'Bench evaluation of Flow Limitation Detection by Automated Continuous Positive Airway Pressure Devices'. Frederic Lofaso, Gilbert Desmarais, Karl Leroux, Vincent Zalc, Redouane Fodil, Daniel Isabey, Bruno Louis. France.
I just took a look at the summary info - Manuscript was received Dec 7 2005 & was it was published in August 2006 (is a reprint from Chest magazine).
http://www.chestjournal.org/
The conclusion below reflected his comment to me. ...
Study Objective:
Automatic continuous positive airway pressure (CPAP) devices that adjust the pressure delivered to the patient are now available to treat sleep-disordered breathing. Sophisticated auto-CPAP devices can detect and correct flattened inspiratory flow contours (FIFCs) associated with subtle upper airway obstruction. However, evaluations of their performance are made difficult by the differences across patients and devices. We performed a bench study of five commercially available auto-CPAP devices using a breath waveform simulator to evaluate sensitivity for detecting flattened inspiratory flow.
Design:
Five degrees of FIFC were simulated. In addition, normal and abnormal flow contours from patients published in literature were evaluated.
Measurements and Results:
One device showed autotriggering leading to CPAP increases, and another device varied the CPAP level independently from the presence of an FIFC. The three remaining devices differed regarding the detection of FIFCs and the means used to increase CPAP.
Conclusion:
Based on the characteristics of each patient, physicians must choose among devices with different thresholds of FIFC detection and different pressure responses to detection. Therefore, physicians need details on the algorithms used in auto-CPAP devices. Manufacturers should supply detailed algorithms.
(CHEST 2006: 130:343-349)
*FIFC = flattened inspiratory flow contours.
He also mentioned another Australian report that he says goes into great detail on the variation caused by the differing deadspaces & vent hole sizes in different types & styles of masks.
DSM
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
BRAVO!!!!!!!!
Bravo DSM!!!!
Its what I've been saying ALL ALONG!!!
Its SO IMPORTANT to TRY BEFORE YOU BUY the different algorithms between manufacturers!!!!! They are SO DIFFERENT and have such different results, depending on the individual patient.
Thank you so much Doug!!!!
Chuck
Its what I've been saying ALL ALONG!!!
Its SO IMPORTANT to TRY BEFORE YOU BUY the different algorithms between manufacturers!!!!! They are SO DIFFERENT and have such different results, depending on the individual patient.
Thank you so much Doug!!!!
Chuck
People are dying every day in Darfur simply for who they are!!! PLEASE HELP THEM!
http://www.savedarfur.org
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Re: MD Feedback
[quote="Lubman"]dsm
It's good that he straightened out the 13 versus 15, even if you had identified it on your own. Great validation.
I have not heard of Positive Airway Ventilation, but I do find it interesting that both ResMed and Respironics both call it Adaptive Servo Ventilation, which implies that neither own the IP rights to the term.
Take care
Lubman
It's good that he straightened out the 13 versus 15, even if you had identified it on your own. Great validation.
I have not heard of Positive Airway Ventilation, but I do find it interesting that both ResMed and Respironics both call it Adaptive Servo Ventilation, which implies that neither own the IP rights to the term.
Take care
Lubman
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
Re: BRAVO!!!!!!!!
Chuck - Tks,GoofyUT wrote:Bravo DSM!!!!
Its what I've been saying ALL ALONG!!!
Its SO IMPORTANT to TRY BEFORE YOU BUY the different algorithms between manufacturers!!!!! They are SO DIFFERENT and have such different results, depending on the individual patient.
Thank you so much Doug!!!!
Chuck
I quoted your ref to your own experience in another thread. That kind of detail when clearly said from the heart is very useful data & very helpful in seeking understandings about CPAP. I noted your comments about EPR as well. That is as close to what my own machine is running as it can get (10/13).
My physician really pushed me about why I have a Bilevel. I really didn't have the time I wanted to go into all the detail but I will be doing more thinking about it. He kind of had me on the spot re the 13 cms being my recommended epap level.
My logic re this matter was like this ...
If I am breathing in and the Bilevel is in IPAP mode and at 13 then I have the cms needed to keep my airway open this seems to be the critical part to my way of thinking , if I start to breath out then the Bilevel switches to epap mode & drops to say 8 or 10 or whatever I set it to, I am ok because this is breathout time & not when an apnea is going to occur.
Ending the exhale cycle (a) >
If I then stop breathing it is usually because I have ended the exhale cycle and this Bilevel will switch instantly back to the 13 cms needed to inflate my airway & allow me to breathe in as I should. It triggers on the tiniest wiff of air in.
Ending the exhale cycle (b) >
If however I reach the end of the exhale cycle & the machine is sitting at 8 or 10 or whatever & waiting for me to breathe in, even just a wisp, and I don't because at that very instant I experience an airway collapse and there is no inward flow for the machine to pick up on, then I can see that being at too low a CMS would be a problem. DSM has an Apnea. I guess this is one reason I like the PB330 as it has an extra trick up its sleeve in that if within 4 secs I haven't started breathing again it goes to IPAP anyway. 4 secs is pretty quick.
Maybe the PB330 machine has been shielding me from the problem that then showed up so clearly when I used the VPAP III machine I got hold of (which is the model without the timed control). The VPAP III at 8/15 was showing me having an AHI of 40+ up to 60+ every night while I used it until I changed its ipap to 13 & the epap to 10 at which time the AHI went down to 2.5 & less.
However, I will do some more testing - perhaps set epap at 11 & ipap at 14 & see how I go - I am getting to like being at 13 - mask leaks have all but gone away. I no longer use or seem to need a chinstrap.
DSM
On this topic, the more I learn the less I discover I know.
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
Re: Surprise surprise !
[quote="dsm"]Went to my sleep specialist today - haven't seen him since before going on cpap in mid 2005. Here is a frank and honest report on the meeting that took place & some of the matters discussed. Contained a few surprises for me
In his hello he read the summary from my sleep study saying "and your titration recommendation was 13".
WHAT says I, I was told 15!. In fact I phoned the sleep clinic back when setting up my machine to ask if the handwritten note stating the titration cms was a 13 or a 15 as it was not easy to read. The clinic came back with 15. So for over 18months (until I recently lowered the cms to 13 based on my own home study) I had been running the machines at 15 as the main cms setting.
The difference between 14 and 15 for me is that it has always been the threshold for mask leaks - and all the other extra surprises we get when we go to higher cms settings (aerophagia etc:)..
The other point that this sleep specialist made during discussions & going over the results of some of the testing I had done, was that the titration of 13 IS THE MINIMUM cms they recommend for cpap for me. It is the number at which I am likely to have events if my pressure is set below that number.
He pointed out that me setting my epap to 8 was too low and that was why the bad results had shown up with the bilevel set to 8/15. He stated again that the titration number was in effect the epap!. It is the threshold at which AI & HI events are best contained!.
He has requested another sleep study (routine & free to us here in Aust) for feb next year & has said that he wants to do it as a split study partly with my fav UMFF mask & partly with my fav nasal pillows (an Adams Circuit mask).
He said it was a known fact backed up by published reports (covering the deadspace issue) that almost every mask is going to change the ideal titration and that nasal pillows masks typically require a slightly lower cms setting (depending on the actual model).
We got to discussing Resmed's price hike & he said didn't you know they just built a massive new factory ?. They have to pay for it somehow"
His comments on the issue of Autos vs Cpaps was
"Autos provide you with unneeded Bells & Whistles! - go buy yourself a Remstar Pro with a smartcard - thats all anyone on straight cpap therapy needs!" (I told him I already had 1 (or 2 (or ? ))) - "That one is all you need" says he!. When pressed, he said that in his profession, they were not happy about the auto algorithms that the manufacturers won't disclose. He said they claim they are proprietary but he considers that so much b*lls**t !" -- (very outspoken Dr this one ).
I mentioned what I had read about of the Adaptive Servo Ventilation machines. His comment was that has been around in principle for a while & known as PAV (Positive Airway Ventilation). He said that from his perspective there was no evidence that all the extra technology made any difference for the normal cpap user. A straight CPAP was still the best and most effective solution & that unless someone had a specific need for such a machine it was more than what is needed. He agreed that recording nightly data was very valuable for all concerned.
He appreciated the data I had gathered & when I mentioned it was on the Internet he asked if I had any details on the numbers of 'hits' to the data. He said he believed it would get a lot of interest & asked me to track it.
DSM
In his hello he read the summary from my sleep study saying "and your titration recommendation was 13".
WHAT says I, I was told 15!. In fact I phoned the sleep clinic back when setting up my machine to ask if the handwritten note stating the titration cms was a 13 or a 15 as it was not easy to read. The clinic came back with 15. So for over 18months (until I recently lowered the cms to 13 based on my own home study) I had been running the machines at 15 as the main cms setting.
The difference between 14 and 15 for me is that it has always been the threshold for mask leaks - and all the other extra surprises we get when we go to higher cms settings (aerophagia etc:)..
The other point that this sleep specialist made during discussions & going over the results of some of the testing I had done, was that the titration of 13 IS THE MINIMUM cms they recommend for cpap for me. It is the number at which I am likely to have events if my pressure is set below that number.
He pointed out that me setting my epap to 8 was too low and that was why the bad results had shown up with the bilevel set to 8/15. He stated again that the titration number was in effect the epap!. It is the threshold at which AI & HI events are best contained!.
He has requested another sleep study (routine & free to us here in Aust) for feb next year & has said that he wants to do it as a split study partly with my fav UMFF mask & partly with my fav nasal pillows (an Adams Circuit mask).
He said it was a known fact backed up by published reports (covering the deadspace issue) that almost every mask is going to change the ideal titration and that nasal pillows masks typically require a slightly lower cms setting (depending on the actual model).
We got to discussing Resmed's price hike & he said didn't you know they just built a massive new factory ?. They have to pay for it somehow"
His comments on the issue of Autos vs Cpaps was
"Autos provide you with unneeded Bells & Whistles! - go buy yourself a Remstar Pro with a smartcard - thats all anyone on straight cpap therapy needs!" (I told him I already had 1 (or 2 (or ? ))) - "That one is all you need" says he!. When pressed, he said that in his profession, they were not happy about the auto algorithms that the manufacturers won't disclose. He said they claim they are proprietary but he considers that so much b*lls**t !" -- (very outspoken Dr this one ).
I mentioned what I had read about of the Adaptive Servo Ventilation machines. His comment was that has been around in principle for a while & known as PAV (Positive Airway Ventilation). He said that from his perspective there was no evidence that all the extra technology made any difference for the normal cpap user. A straight CPAP was still the best and most effective solution & that unless someone had a specific need for such a machine it was more than what is needed. He agreed that recording nightly data was very valuable for all concerned.
He appreciated the data I had gathered & when I mentioned it was on the Internet he asked if I had any details on the numbers of 'hits' to the data. He said he believed it would get a lot of interest & asked me to track it.
DSM
Snoredog,
Having read through a couple of thase patents. I agree, the detail is there, certainly in the ones I read.
The study mentioned comes from France & was published in the August edition of the US journal CHEST so is obviously just being digested by respiratory doctors around the world.
The fact that my doc printed a copy off for me sure shows he considers the info to be relevant.
I will read through the whole report tonight & see what I can glean from it. I am happy to clarify this as it is relevant to us.
I will try to find just what they mean in the report in regard to making the algorithms known.
Good point
DSM
Having read through a couple of thase patents. I agree, the detail is there, certainly in the ones I read.
The study mentioned comes from France & was published in the August edition of the US journal CHEST so is obviously just being digested by respiratory doctors around the world.
The fact that my doc printed a copy off for me sure shows he considers the info to be relevant.
I will read through the whole report tonight & see what I can glean from it. I am happy to clarify this as it is relevant to us.
I will try to find just what they mean in the report in regard to making the algorithms known.
Good point
DSM
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
SD
Some snippets ...
The machines tested are listed as ...
1) Goodnight 418P
2) goodnight 420E
3) Resmed Autoset Spirit
4) Respironics Remstar AUTO
5) Breas PV10i
DSM
FIFCs = Flattened Inspiratory Flow Contours
In scanning thru the report they focus on these FIFCs - their tests were it seems to determine what the machines responses are to FIFCs rather than any other specific type of breathing pattern.
As I don't really know what they are meaning precisely by FIFCs I trust some other of our folk here will offer some explanation.
D
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): 420E, respironics, resmed, auto
Some snippets ...
The machines tested are listed as ...
1) Goodnight 418P
2) goodnight 420E
3) Resmed Autoset Spirit
4) Respironics Remstar AUTO
5) Breas PV10i
DSM
FIFCs = Flattened Inspiratory Flow Contours
In scanning thru the report they focus on these FIFCs - their tests were it seems to determine what the machines responses are to FIFCs rather than any other specific type of breathing pattern.
As I don't really know what they are meaning precisely by FIFCs I trust some other of our folk here will offer some explanation.
D
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): 420E, respironics, resmed, auto
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
-
rested gal
- Posts: 12881
- Joined: Thu Sep 09, 2004 10:14 pm
- Location: Tennessee
Again, another study using an artificial breathing machine. I would think the same problem applies to that kind of "testing" various autopaps' response as when the McCoy/Eiken tests (also using an artificial breathing machine) were done. No feedback from a real patient in the circuit. All autopaps rely on what changes, for better or worse, they get back from the patient in response to the machine's initial action when confronted with a limited air flow situation.dsm wrote:The study mentioned comes from France & was published in the August edition of the US journal CHEST so is obviously just being digested by respiratory doctors around the world.
The fact that my doc printed a copy off for me sure shows he considers the info to be relevant.
Again, as with previous tests using an artificial breathing machine, "lobbing" (to use -SWS's cool word) the same breathing pattern at different autopaps without a human in the loop to see what the machines would do with response from a patient... it's a meaningless comparison of machines, as well as no useful indication of what they can or would actually do while treating living, breathing people, imho.
As Snoredog put it:
"Only problem is no human breathes like a machine and every patient is different."
dsm wrote:In scanning thru the report they focus on these FIFCs - their tests were it seems to determine what the machines responses are to FIFCs rather than any other specific type of breathing pattern.
As I don't really know what they are meaning precisely by FIFCs I trust some other of our folk here will offer some explanation.
I may be wrong, but I think Flattened Inspiratory Flow Contours refers to the shape of the top of the wave form as shown in a histogram. The more limited the air flow being "breathed in", the flatter the top will look. Sounds like they had the artificial breathing machine set to deliver different degrees of limited air flows. Different degrees of hypopneas, if you will -- and if you disregard the Medicare definition of hypopneas as having to show at least a 4% drop in O2.
ResMed S9 VPAP Auto (ASV)
Humidifier: Integrated + Climate Control hose
Mask: Aeiomed Headrest (deconstructed, with homemade straps
3M painters tape over mouth
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Humidifier: Integrated + Climate Control hose
Mask: Aeiomed Headrest (deconstructed, with homemade straps
3M painters tape over mouth
ALL LINKS by rested gal:
viewtopic.php?t=17435
Rested Gal,
Thanks
That description of the FIFCs works for me. The do highlight the words Flow Limitations in the heading (IIRC).
They do mention a breathing machine developed in the US plus a modification they developed to allow them to focus on FIFC and to feed in via a PC, patterns extracted from published reports on 'real' people.
I am open minded on the significance of these types of studies. No studies at all is not viable, but as has been pointed out, it can be difficult to get any simulator to mimic some aspects of CPAP, but, if they have focussed on an aspect they can measure with some degree of acceptability within their medical community, I guess they may be taken notice of.
The comments re the individual machines in regard to response to FIFCs was very negative. None got any real plusses.
DSM
Thanks
That description of the FIFCs works for me. The do highlight the words Flow Limitations in the heading (IIRC).
They do mention a breathing machine developed in the US plus a modification they developed to allow them to focus on FIFC and to feed in via a PC, patterns extracted from published reports on 'real' people.
I am open minded on the significance of these types of studies. No studies at all is not viable, but as has been pointed out, it can be difficult to get any simulator to mimic some aspects of CPAP, but, if they have focussed on an aspect they can measure with some degree of acceptability within their medical community, I guess they may be taken notice of.
The comments re the individual machines in regard to response to FIFCs was very negative. None got any real plusses.
DSM
xPAP and Quattro std mask (plus a pad-a-cheek anti-leak strap)
-
rested gal
- Posts: 12881
- Joined: Thu Sep 09, 2004 10:14 pm
- Location: Tennessee
Yep. EPAP pressure on a bi-level machine is supposed to be set at a level to prevent apneas.dsm wrote:He pointed out that me setting my epap to 8 was too low and that was why the bad results had shown up with the bilevel set to 8/15. He stated again that the titration number was in effect the epap!. It is the threshold at which AI & HI events are best contained!.
viewtopic.php?t=1926
Discussion on cpaptalk about how bi-level titration is done:
-SWS: "They initially titrate to clear apneas using a straight pressure. They then take that fixed pressure value as their initial EPAP setting (not IPAP)"
-Titrator: "Here is how and why you titrate for a bilevel machine.
You start at 4cm for both IPAP and EPAP. You then bring the I and the E up at the same time and same pressure until APNEA events are cleared. Apnea, meaning a complete blockage with no breathing for at least 10 seconds. Apnea happens at the end of EPAP, so the EPAP has to be enough to keep your airway open.
You then leave the EPAP at the point where apnea stops, and concentrate on any flow limitation, snore, and hypopnea. This is done by raising the IPAP."
And from: http://www.ent.health.ufl.edu/files/for ... ap2000.pdf
University of Florida Sleep Disorders Center (5/31/2000)
Standard Positive Pressure and Oxygen Titration Guidelines (adult)
9. Bilevel pressure will be titrated as follows. IPAP = EPAP will be increased until apnea abolished. Then IPAP increased until hypopnea /snoring/desaturation are abolished. If events persist despite the maximum tolerated IPAP, then the EPAP will be increased in 1 cm H2O increments.
ResMed S9 VPAP Auto (ASV)
Humidifier: Integrated + Climate Control hose
Mask: Aeiomed Headrest (deconstructed, with homemade straps
3M painters tape over mouth
ALL LINKS by rested gal:
viewtopic.php?t=17435
Humidifier: Integrated + Climate Control hose
Mask: Aeiomed Headrest (deconstructed, with homemade straps
3M painters tape over mouth
ALL LINKS by rested gal:
viewtopic.php?t=17435
-
rested gal
- Posts: 12881
- Joined: Thu Sep 09, 2004 10:14 pm
- Location: Tennessee
Not surprising. Given a "no patient response" type of test, none of the individual machines were allowed to actually demonstrate what they can do with a sleep disordered breathing person giving the machine feedback as the machine goes about its designed-in work.dsm wrote:The comments re the individual machines in regard to response to FIFCs was very negative. None got any real plusses.
ResMed S9 VPAP Auto (ASV)
Humidifier: Integrated + Climate Control hose
Mask: Aeiomed Headrest (deconstructed, with homemade straps
3M painters tape over mouth
ALL LINKS by rested gal:
viewtopic.php?t=17435
Humidifier: Integrated + Climate Control hose
Mask: Aeiomed Headrest (deconstructed, with homemade straps
3M painters tape over mouth
ALL LINKS by rested gal:
viewtopic.php?t=17435