Best autopap for RERAS, UARS

[parrotfish2]

I had a sleep study done at Sleep Medicine Associates and was diagnosed with sleep apnea. However my study showed many more RERAs than apneas or hypopneas: AHI of 10 and RERA of 24. I also fit the description of the classic UARS patient: low blood pressure, cold hands and feet, not overweight, female. Sleep Medicine Associates doesn't hold with that diagnosis and in my case it doesn't matter -- since I also fit the definition for apnea. But in terms of treatment I think it may matter.

I didn't want to return to SMA for a titration night because during my original study I only got 3 hours of sleep, none of it REM sleep. So instead I went to another doctor who prescribed a REsMed S9 Autopap. Once I figured out how to keep it from shutting off at night, I have been using it every night -- I'm only 4 nights away from being compliant for my insurance. For a while I felt like the machine was helping but then it stopped and I feel just as tired as I did before I was using it.

I called the tech at ResMed to ask what the data showed, and he said my AHI was now under 5. However the machine doesn't record RERAs -- I had to explain to the tech what they were. I'd like to keep using an autopap and I know that the different brands have different algorithms. I'm assuming that there is probably a best autopap for catching RERA's and that it isn't ResMed -- since they don't even count them. It could be that no auatopap will work to catch the RERA's because they are too fleeting and that I will have to switch to cpap -- but I'm hoping that is not the case.

[robysue]

The Philips Respironics System One Auto machine is an APAP that attempts to score RERAs. I say "attempts to score" because the System One only has the wave flow data to analyze. It doesn't have an EEG, and hence it cannot tell when a real arousal has actually occurred, and, of course, on a PSG an EEG arousal is required to score a RERA.

On the System One machines RERAs seem to be scored when the machine detects a wave flow pattern that statistically stands a very good chance of being a RERA based on the shape of the airflow before, during, and immediately after the RERA. How accurate is this algorithm? I haven't the foggiest idea whether it's been analyzed for effectiveness by folks not associated with Philips. But clearly the folks at Philips believe the algorithm is sufficiently accurate to be used to get at least a ball park idea of whether you're getting a boatload of such events or only a handful. And the PR S1 Auto will increase the pressure if two or more RERAs occur sufficiently close together or if a RERA occurs along with snoring or flow limitations.

NOTE: The PR System One PRO CPAP also records RERAs, but as a fixed pressure machine it does not respond to them.

NOTE: The PR System One BiPAP PRO and BiPAP Auto also record RERAs. The BiPAP Auto will increase the IPAP in response to two or more RERAs that are sufficiently close to each other if I recall correctly.

[avi123]

Do you have stuffy nose from allergy or air flow (Vasomotor) Rhinitis, or deviated septum?

I have a Vasomotor Rhinitis which comes from the XPAP air flow and its temp. My Resmed S9 APAP in APAP mode with max pressure of 15 cm and 10 cm as min, does a pretty good job clearing my nose after I squirt it with Salted Saline (Ayrs). I do better (the ResScan Flow Limitation graph is below its middle value than otherwise) if I use this combination of mask and chin strap:

This kind of nasal mask:

add http here ://www.cpapsupplyusa.com/6160x-ResMed-Mira ... dgear.aspx

And this kind of chin strap OVER the mask's straps:

add http here ://www.cpap-experts.com/cpap-chin-straps/r ... ap-premium

By using this combination the Resmed S9 Autoset responds much differently than by using a full face mask. It immediately reduces the flow limitation and eliminates almost all obstructive events. Once these are done it stays at the lowest pressure of 10 cm. Because I set the EPR at 3, I end up exhaling into a pressure of 7 cm which I find it to be comfortable. Otherwise, I would try a BiLevel. But not run it in Auto mode b/c then it would keep changing pressures on its own and this could cause instability in my respiration regime and wake me up.

[robysue]

Avi,

I'm not sure of the point of your post. The problem in UARS goes beyond just flow limitations. The problem is that the flow limitations are frequently associated with arousals.

And there's just no good way to detect arousals on either the Resmed or Philips Respironics platform because there is not an EEG attached to the machine. PR, however, has studied the wave forms of PSG scored RERAs and they believe they've come up with a wave form profile that statistically is associated with RERAs. And that's what they use to score the RERAs.

As for ways to get around the lack of an EEG, the obvious do-it-yourself "solution" is to add a zeo to the sleep paraphernalia. But even so, the zeo is of limited value it trying to tease out when a flow limitation might be a RERA because the zeo only has three forehead pads for detecting EEGs and because of problems getting the zeo's clock and the PAP's clock truly synced. Even the detailed data available for download from the web site is scored in 30-second periods, which may be too long to detect a RERA's short-lived arousal AND the zeo has a tendency to mis-score wake/light/rem sleep up to 25% of the time for some users.)

Now, theoretically eliminating the flow limitations should eliminate the RERAs, which is why PAP is the recommended treatment for UARS. But it's possible to have the S9 detect an OA or a H** without a big dip in the Flow Limitation graph, and so it's reasonable to assume that RERAs could also occur without a noticeable dip in the Flow Limitation graph.

**NOTE: During the three months I used the S9 Autoset (in both CPAP and Auto modes), the vast majority of my OAs and Hs were scored at times where there was no dip or only a very minor dip in the FL graph. Indeed, unlike you, my FL graph seldom ever dropped below the 50% line even in my worst clusters. And at the time I was using the S9, I was still largely ignoring my fall seasonal allergies---i.e. no Flonase, no neti pot, no saline nasal spray, and no zyrtec on a nightly basis.

[avi123]

As I understand it from Dr Barry Krakow:

(Dr Barry Krakow about Flow Limitation)

A reminder that for all practical purposes, the following three terms are interchangeable:

• UARS (upper airway resistance)
• Flow limitation
• RERAs (respiratory effort-related arousals)

You are probably familar with Dr Krakow's report on this subject matter that he posted in this forum and in his own website:

Link:

http://sleepdynamictherapy.com/2007/12/ ... y-results/

[avi123]

I would like to add to this thread about what Dr Michael Berthon-Jones the developer of Resmed's APAPs machines
said on this subject matter in an interview from 2002 :

Question:

Why is it important for an automatic CPAPdevice
to respond to flow limitation, snore and apnea?

Dr Berthon-Jones reply:

The characteristic flattening of the flow-time
curve caused by flow limitation is the very best
signal for fine-tuning the pressure, once you have
eliminated apneas and snoring. But if you are just
falling asleep, you can go very quickly from having
a totally open airway to snoring very loudly, in a way
that produces somewhat chaotic or messy flowtime
curves, without seeing the characteristic
flattening. So the best approach is to respond very
quickly to loud snoring, and then fine tune using
flattening. Rarely, you can go straight from awake
and unobstructed to asleep and apneic, and so it
can be useful to increase pressure in response to
apnea as well. However, actual apnea is pretty rare
on AutoSet, because in most cases the responses
to snoring and flattening get the pressure up
quickly enough to prevent apneas.


It seems to me that I see the above explanations while I use my S9 Autuset. And I am NOT being awaken.

I set the APAP on 15 cm max and 10 cm min with EPR = 3, at full time.
I use a combination of a nasal mask and a chin strap as I mentioned in my above posts.

The machine first takes care of obstructives (I don't snore much) by using the max pressure.
Then it fine tunes to eliminate Flow Limitation by surprisingly lowering the pressure to the min level.
Then it stays on the min pressure for the rest of the night. This offers me an exhale pressure of 7 cm thru the EPR=3
Only about 4 Centrals show up lasting less than 35 sec.

Any thoughts?

[KrisasMan]

I would also be interested to know the best machine for RERAs. Out of curiosity I recent changed my machine from CPAP to Auto mode and found that my 'Flow Limitations' were quite a bit higher, jumped from 0.34 average to 1.95. The surprising thing is my F&P Icon didn't respond to anything but Apnea and Hypopnea events, completely ignoring the regular 'Flow Limitations' that lead to a poor night sleep.

Do all machines so this? Is there a setting I am missing? It seems clear to me that if you are having flow limitations which often = RERAs the machine needs to bring up the baseline pressure or at least try to compensate by bringing it up temporarily.

For me the solution is easy, up the pressure. Luckily I tollerate my CPAP pressure just fine but I would hate to be in the situation where I could only tollerate a Auto and not have it reacting to my RERAs.

[robysue]

The surprising thing is my F&P Icon didn't respond to anything but Apnea and Hypopnea events, completely ignoring the regular 'Flow Limitations' that lead to a poor night sleep.

Do all machines so this? Is there a setting I am missing? It seems clear to me that if you are having flow limitations which often = RERAs the machine needs to bring up the baseline pressure or at least try to compensate by bringing it up temporarily.

Can't speak for other machines, but the PR System One BiPAP Auto that I use most certainly increases the IPAP for flow limitations and RERAs.