.

[NotMuffy]

...do you have a picture/graphic of what recovery breaths look like? If I had to guess, I would guess that they show up as a pile of taller and skinnier waveforms (is that the right word?) in the flow.

As luck would have it, this shows 3 areas of FL, with some recovery breaths following the first two:



RERAs can be subtle, so there may not be huge "resuscitive" breathing post event, but this example clearly shows several "rounded breaths" post-FL, with the first series more obvious than the second.

So then in the unlikely case that the settings were incorrect, it is possible to go back and confirm whether or not the arousals are spontaneous or FL related.

Absolutely. And that aforementioned error is rare. I mean, nobody does that.

OK, maybe one person.

...I'm all for Techno-flash, but please, please don't turn the background fuchsia, it hurts my eyes and makes me cranky.

Too late!



BTW, that's not FL, that's FOT.

[NotMuffy]

So EPR turned on tends to help the FLs as opposed to CPAP or APAP with EPR off?

I don't believe EPR, as an expiratory comfort measure, has anything to do with Inspiratory Flow Limitations.

[NotMuffy]

Is flattening of the nasal pressure waveform = FL? If so, is that still an integral part of the criteria?

Yes, and consequently, absolutely.

{BiLevel may be worth investigating in cases) where the person appears to have FLs on CPAP and continued EDS?

No, in cases of RERAs. FL without arousals is nothing (TS, refer to articles re: any snoring is bad snoring).

OK, so is there a way to tell from CPAP data whether it's a pressure-responsive or flow-responsive FL?

Yes.

...and are those mutually exclusive or can a person have both?...

I would argue that once one uses a bilevel anything to attack FL, the entire approach becomes flow-, and not pressure-oriented.

Meaning that in those cases, the residual FLs are not likely to be the cause of the EDS?

You have to careful about terminology. If by "residual FLs", you mean "RERAs", then they need to be addressed.

If you mean "FLWs", then that remains forum fodder.

And short of the person being aware of poor sleep efficiency, how do we know if there's a sleep problem vs. an SDB problem?

Careful review of the history, physical, machine DLs and PSG data.

[NotMuffy]

Funny thing is, sleep medicine finds itself in the awkward position of its testing costing much more than simply trying the treatment, too.

Your generalizations and syllogisms should add another 300 replies to this thread, jeff!

But let me comment on that one above, because it's kinda like what your buddy up there is saying with his "Get an 'app'", because he thinks that "apps" just magically appear shortly after a problem surfaces, and DLing something off iTunes will fix everything (the equivalent of MechaMuffy saying "Can't you just", as in when I'm driving down the road, and suddenly the car stutters and comes to a halt, and I look in the rear view mirror and there's smoke, and gears, and oil, and jaggered chunks of metal, and we're out in the middle of nowhere, and she says

[NotMuffy]

Alls I got to say is, if you came to this thread late, it's going to be a little difficult to get caught up.

[jnk]

Funny thing is, sleep medicine finds itself in the awkward position of its testing costing much more than simply trying the treatment, too.

Your generalizations and syllogisms should add another 300 replies to this thread,

I admit it. I was trying to bait you into keeping the thread going. I am interested in your take on that "position"--help given by sleep docs who don't understand the technology.

I much prefer the way YOU have kept the thread going, though.

My worry is that sometimes patients think: "I need another sleep study to see if I'm having flow limitations so I can start treating THEM instead of just treating apneas and hypopneas." I think if they walk into a doc's office and say that, they are more likely to make a doc mad than to get any sympathy and action.

On the other hand, if they, as patients, walk into the same doc's office and say "I am still sleepy and tired and still wake up feeling like doggie-doo," they are much more likely to get help with an adjustment of pressure, a different machine, or a thorough examination of other health issues and sleep hygiene, etc.

And if a patient walks into a doc with his S9 flow printouts to prove RERAs, the doc may be less than entertained by that, even though I have no doubt it could be done.

The kind of stuff you have posted in this thread is some of the most valuable stuff anywhere on the Web for patients with sleep problems, in my opinion. The help you provide to people like secret agent girl and others is some of the most amazing interaction I've seen occur anywhere, as far as being valuable to other patients and professionals who happen by here. What I appreciate most is that you not only explain things about the technology of the testing and treatments and the intricacies of how they can both be used to help patients but you also point out the broad overview and the various positions by researchers and practitioners. That kind of insight, experience, and perspective is very much appreciated.

That's why I stooped to baiting you. Not trolling. Just trying to do my part to keep you posting. It's a fine line for me sometimes. Sorry.

[SleepingUgly]

The S9, unfortunately, does not report RERAs like the PR System 1 (which we know is reporting some kind of proxy for RERAs because it can't know about the arousals). It does show FL limitation graphs. My FLs don't look great. So I assume the idea is that we work off the assumption that the FLs are causing arousals, and that I keep increasing the pressure until they look better, and see if my EDS improves as a function of that? (The only problem with that is that CPAP seems to introduce many arousals/awakenings due to the apparatus, leaks, etc. that often seems to yield at least as much sleep disruption as it solves).

BTW, could FLs cause EDS by any other mechanism other than arousals, such as disruption of sleep architecture or more work/effort in breathing or something else?

[carbonman]

The kind of stuff you have posted in this thread is some of the most valuable stuff anywhere on the Web for patients with sleep problems, in my opinion.

I agree. Good stuff.
I start throwing this stuff at my hosehead friends that
do not visit cpaptalk and their eyes glaze over...
Good stuff.

So I assume the idea is that we work off the assumption that the FLs are causing arousals, and that I keep increasing the pressure until they look better, and see if my EDS improves as a function of that?

....wait for it....here it comes.....BUT....
after all the education, hypothesizing, speculating,
pontificating, fantasizing and finally realizing....
in the end, all we can really do is adjust the pressure
and see what happens.

[jnk]

. . . adjust the pressure and see what happens.

You spandex-wearin' dial-winger, you! NotMuffy may kill us BOTH now!

Does this make us the new banned/dsm team of the board?

[carbonman]

You spandex-wearin' dial-winger, you!

.... HEY ....I resemble that remark.

NotMuffy may kill us BOTH now!

To Infinity.....and beyond.

Does this make us the new banned/dsm team of the board?

Just trying to do my part to keep the "." alive.

[-SWS]

Well, then please allow me to inject another divertisement:
https://www.youtube.com/watch?v=vpk5LyE806k

Moral of the above story: an unvaried diet is nary a diet...

(back to our regularly scheduled dot-program)

[Rebecca R]

As luck would have it, this shows 3 areas of FL, with some recovery breaths following the first two:



RERAs can be subtle, so there may not be huge "resuscitive" breathing post event, but this example clearly shows several "rounded breaths" post-FL, with the first series more obvious than the second.

Thanks for the examples. They are much more subtle than I imagined.

...I'm all for Techno-flash, but please, please don't turn the background fuchsia, it hurts my eyes and makes me cranky.

Too late!

BTW, that's not FL, that's FOT.

Right. FOT.

[NotMuffy]

As luck would have it, this shows 3 areas of FL, with some recovery breaths following the first two:



RERAs can be subtle, so there may not be huge "resuscitive" breathing post event, but this example clearly shows several "rounded breaths" post-FL, with the first series more obvious than the second.

Thanks for the examples. They are much more subtle than I imagined.

Well, I am so disappointed that no one challenged these to actually be hypopneas.

[jnk]

My best attempt to water the mud, from a 13-yr-old article:

"Flow limitation may curtail periods of deep sleep, even when the degree of flow limitation was not sufficient to be associated with transient cortical electroencephalogram (EEG) arousals. . . . Even in the absence of sleep-disordered breathing events it may prevent the occurrence of optimal sleep architecture . . . In turn, these nocturnal perturbations often predispose to chronic daytime pathophysiology."

"The biologic significance acutely and/or longer term, of a given degree of flow limitation is likely to vary widely and often unpredictably. For example, healthy subjects and those in heart failure will vary greatly in the effects of negative intrapleural pressure on left ventricular afterload and stroke-volume. Furthermore, arousability in response to a given level of pleural pressure development will vary even within a subject as sleep state changes."

"We . . . need to understand more about what factors contribute to variability among subjects in terms of their acute and chronic biologic responses to a given magnitude (and duration) of air flow limitation."

Am. J. Respir. Crit. Care Med., Volume 158, Number 3, September 1998, 713-722

http://171.66.122.149/cgi/content/full/158/3/713

[jnk]

And then from a 10-yr-old article:

"There is still much disagreement on the type and level of respiratory abnormality that must be used as a "cutoff" for significant disease (e.g., obstructive sleep apnea syndrome [OSAS] and upper airway resistance syndrome [UARS]). . . . Part of the problem lies in not knowing the degree of biological variation in the number of respiratory events that exists in subjects who are asymptomatic and have no evidence of long-term morbidity ("normal" subjects)."

"Because of the ambiguity in the definition of respiratory events, treatments to relieve symptoms of snoring and excessive daytime somnolence are being applied on clinical grounds with only indirect proof of any respiratory abnormality. Thus, for example, frequent arousals or response to continuous positive airway pressure (CPAP) are used as evidence that upper airway disease was present and of respiratory origin. . . . Even with the most ideal metric for representing the physiology of sleep-disordered breathing, differing sensitivity of individuals to the same level of respiratory stress results in differing levels of symptoms."

Am. J. Respir. Crit. Care Med., Volume 163, Number 2, February 2001, 398-405

http://ajrccm.atsjournals.org/cgi/conte ... /163/2/398