CPAPtalk.com

It's remarkable. I can nearly echo Miss Emerita as is reflected below in the elisions or braces-enclosed, bolded underlined and italicized fonts showing my parallels applied to places in her post.

Her contrasting FL graphs from the Autoset and VAuto show the same improvement I experienced with only that 1.0 cm of added PS, beyond what the Airsense Autoset could do with EPR 3. It was the similarity of her graphs to mine showing the change that stopped me cold to make this comment. Only 1.0 cm of pressure change, if in fact that is the only difference between the machines, can make a huge difference in FL. I still have a lot of sub-detectable (I'll say fl rather than FL) that shows up in small deformations of the FR curve at peak inhalation flow. Sleep is vastly improved, but I am still searching for ways to, er, "unflatten the curve[s]", particularly those (zoomed 1-minute view) peaks with two ears--that almost always trigger a FL for him--and those undetected flow resistances just below that two-eared level of interference.

AGAIN, MISS EMERITA'S ACTUAL QUOTE HAS BEEN MODIFIED BY ASB IN WHAT FOLLOWS, BETWEEN **** MARKS, TO REFLECT HIS VERY SIMILAR EXPERIENCE OF THE VAUTO'S PS BENEFITS.
***For what it's worth, I bought a lightly used ResMed VAuto Aircurve {$300 for very low hours}. . . . I knew my AHI with the Airsense 10 Autoset was way too low to get a prescription for a bilevel machine or to get insurance coverage. With pressure support of {[4.0]}, I've seen a major change in flow limitations. . . .
.
I definitely feel more rested with the drop in FLs . . . . See attachments for before/after graphs.

Like you, I have cardioballistic artifacts, but they {[are more prominent, side sleeper that I am, when sleeping on my right side than--though still present--when on my left side} The VAuto interprets the fluctuations around the zero line correctly; the Autoset didn't miscount my respiration rate . . . .

Hope this {[near ditto]} is of some help!
[/quote] *****

ASB, how interesting to see the parallels! Nice to know I'm not the only one....

Pineh, about aerophagia, here's a current thread with information from DS about a neat way to work on it -- the Zonker method:

viewtopic/t180038/Aerophagia.html

Miss Emerita wrote: ↑

Tue Aug 18, 2020 10:45 am

ASB, how interesting to see the parallels! Nice to know I'm not the only one....

Pineh, about aerophagia, here's a current thread with information from DS about a neat way to work on it -- the Zonker method:

viewtopic/t180038/Aerophagia.html

Oh look there he is! Shy little feller, isn't he?

Miss Emerita wrote: ↑

Tue Aug 18, 2020 3:15 pm

Oh look there he is! Shy little feller, isn't he?

cute, too!

Pugsy:
Glad to hear that sudden pressure blasts aren't a death sentence for all
I've read a ton about user experiences with ASV, and ASV vs BiLevel since my last post. Indeed many have issues with an ASV while awake, and no (very consistently across users) no apparent issues while asleep. I did run into quite a few posts with people experiencing poor therapy on perfect-looking sleep data from an ASV, however.
I don't think I'll have trouble falling asleep with the PS of either a BiLevel or an ASV - I've certainly done my work to get accustomed to CPAP. Krakow indeed advocates specifically for an ASV, though I have found that at least one of his lectures includes a study where patients had better compliance with an auto BiLevel - so it seems he does prefer BiLevel to CPAP at any rate.

For some strange reason, your experience with a lack of data from now-outdated machines for so many years made me think of the HBO miniseries "Band of Brothers" right away. It sounds like hell. Perhaps the similarity isn't so strange after all! One of my favourite pieces of television of all time, by the way. Anyway, I would go nuts trying to interpret data like that. I've almost gone nuts interpreting the petty graphs the AirSense 10 affords me!

I understand it's tough, perhaps impossible to replicate a VAuto with ASV. I'm shying away from the ASV because it is, after all, an added layer of complexity - and I don't have the central apneas to support the need, even at their worst my CAI are just around 3/h on CPAP as I go through my past few months of graphs, and I haven't seen them that bad in a while. I also encountered just one source saying moderate to severe COPD as a contraindication to ASV - though I couldn't find a real reference (and many references treating COPD with ASV... ). That was a bit of a deterrent to ASV, though luckily I doubt I qualify for anything except maybe mild COPD. Still waiting on a pulmonary test from my current sleep doc who is also a pulmonologist... I don't expect to have one anytime soon with this pandemic. I guess I didn't seem desparate enough at my last appointment a few weeks ago.

Anyway, I've seen quite a few anecdotal experiences where people improved their FLs with a VAuto, and so all I'm really looking for at the moment is the increased PS (and maybe better breath timing) of the VAuto. While I would certainly like to try an ASV, which I can see has been shown to work much more reliably in a wide array of patients than any other PAP therapy - with the added complexity and (importantly) added ~$700 (from secondwind), it's something I might just skip for now. At any rate, I haven't found any 'screamin' deals' on a used ASV in two days' worth of searching... and I am the impaitnet type. If I find the added PS of a VAuto BiLevel to induce centrals, I'll try to tackle them with EERS/added dead space, since I have the components needed for that anyway. I'm hoping that simply increasing my PS in increments of 0.2 will allow me to adjust and avoid too many induced CAs.

AmSleepnBetta - encouraging to hear the VAuto gave you the same improvements to your FLs that I'm seeking! Indeed, the dreaded two-eared deformations have been a nuisance. Now, I think you forgot to attach your before/after graphs - but otherewise, your ditto is a needed reassurance for me to go out-of-pocket for a VAuto, and honestly, I have been dying to do so for months.

Miss Emerita, Zonker - look at that! I guess I've kinda been doing the Zonker method! Except more like increase by 0.2-0.4 every other day, experience discomfort, and wonder where I went wrong I'll be sure to respect the adjustment time. Even still, I can certainly parallel that short pressure bumps have allowed me to be comfortable with higher pressures which at first I felt to be just ridiculous. I actually grew impatient one night and bumped my pressure from 7.6 to 10 as I titrated up by 0.2-0.4 last month, and had the worst abdominal discomfort - even though I had gotten to used to a pressure of 10 before I started my titration! Goes to show that slow and steady is the name of the game.

Without further ado, here's tonight's sleep with the AutoSet standard algorithm. Wasn't so happy when I woke up, which you can probably deduce from the graphs. Ratty flow all throughout the night. Note that I experimented with a 0.3 y-axis cut-off for FLs to see them a bit better in snippets - I'll probably go back to the 0-1.0 y-axis on future posts. Interestingly, AutoSet had my 95% pressure at 11.8 while AutoSet For Her bumped me to a 95% of 13.5! Obvious ugliness in my flow graph seen all throughout the night, even in the absence of recorded FLs: I could include a bunch more evident FLs, but I think we've seen enough for now... so here's what my CAs look like. Seems to be preceded by a sudden cut to a 0 flow at the end of an inhale - looks like a palatal prolapse and/or air entering my mouth (which is taped shut, and covered by a chinstrap - so at least it won't escape!). Not sure whether I should trust the labelling of these events as CAs since they appear to be preceded by obvious (to me) arousals. Hell, I went back a few months and I'm seeing obvious arousals/suspected RERAs before EVERY CA EVER recorded - I'm starting to think they aren't even real CAs! Maybe I'm way off the mark, as my current understanding is that "true CAs" are best identified within a period of otherwise-regular flow. In other news, I've got a sleep consult with a new sleep doc on the 25th. Miraculously, he has even worse reviews than my current/soon-to-be-old sleep doc, and his sleep clinic has absurdly bad reviews ranging from bad technologists, no results for half a year, and most commonly - dirty, unchanged sheets. Great. I'm going to see if I can convince the doc to switch my Rx to a BiLevel so I can get it covered by Ontario insurance... but I'm not so hopeful.

And so, my current lead and plan is an $1100 CAD/830 USD new AirCurve 10 VAuto I've found at a local CPAP store. Definitely not a "used for $300 USD" type of deal... but same price as the $800 USD used Vauto on Secondwind, and I can pick it up in person the same day - a real incentive because damn do I want to figure this out; I need to start applying for work again!
My current task is to wrestle my CPAP Rx out of my Sleep Doc's or my DME's hands. Sleep Doc's office won't pick up calls, so that's a great start.

Hello pineh,

Here are the graphs you thought I forgot. I think you will agree that Miss Emerita's graphs of change in FL could as well have been mine.

I didn't forget to send graphs, just was lazy and didn't want to find and load data from another SD card I had for an AutoSet I sent to a friend. I happened to have recent AutoSet data because I had checked the machine for my friend for a few nights to be sure it was OK, sent him a blank card and kept my old one. My old laptop with a slow hard drive is mainly parked, but has a lot of sleep data on it. I like the solid state memory of the new-to-me laptop I'm using and have grown weary of moving data, programs, wire snarls and wall warts around.

Sorry, my graph comparison is not precisely apples to apples . Among other things, the Autoset session is an hour longer. The graph y-ranges are the same (except Snore) but heights on screen are not exactly equal.
My current VAuto PS is presently only 0.4 cm more than the EPR of 3.0 for the Autoset, not 1.0 where I had long had it for PS 4.0.

My earlier post's key point was, as pugsy mentioned (I think), how a small difference in pressure can change results dramatically.

Thanks for having me revisit FL recorded by the AutoSet. Seeing its FL and sub-FL deformations at peak inhalation flow--in 1-2 minute views mainly with 1- inch+ main amplitude envelope--stroked my present sub-FL-interpretation confirmation biases. The AutoSet recorded one whale of a lot more of those 2-eared peaks, the most prominent of the kinds of "peak" deformation my focus has been on recently. (Most of the time 2-ears will be accompanied by a FL in my records--other significant deformations are seldom followed by a FL within the next breath. The I-E spikes rising and falling to levels far beyond the main FR envelope, as seen from my VAuto FR--this is only my anecdotal data, naturally--are followed in the next breath by a FL in about half the instances. I think those are second bursts of the "I" half cycle are "intended" to clear the low level "fl" that is buiding up and either the spike does so or it fails about half the time and is followed by a FL. Those single-breath spikes are maybe 5-10 minutes apart and are quite noticeably regular in views of my FR for the sleep session.

Trouble is, the only "next things to do/try" for the below-flagging-threshold airflow restrictions gets to such matters as going vegan and/or organic, cuttting dairy, coffee, wee hour blue screen time, and other sleep hygiene matters. Harder to do for an old man than to knock RDI (mostly OSA) down from near 60 to a 3 mo. AHI of 0.1. What is that old German saying, something about "too soon too old, too late smart? But my daughter did tell me, "taught" her old dog dad a trick; the easiest way she knew to assemble multiple image strips and make one image (to keep your image count down) was to use Powerpoint along with Snip It. PP made it super easy to put those two snips on one page. I have rarely touched it over the years.

ASB

ASB, those are indeed the FLs we're after on the AutoSet. Even our pressures are damn near the same. May as well swap SD cards.

Your friend and I are both lucky for your interest in flow graphs I may also note that solid state drives have certainly aged old hardware better than any CPU breakthroughs we've had in the last years.

The small difference between PS and EPR make me think that indeed small pressure differences make all the change, but also that the algorithm of the VAuto is superior to AutoSet for timing breaths properly and dealing with FLs.

I can appreciate the spikes in flow that exceed the main curve envelope. They're something I've wanted to elmininate as well. I can further attest to the difficulty in following perfect sleep hygiene when it extends to all facets of life. Sleep to live, or live to sleep?

That solution to keeping the image count down is something that passed right by me. And here I've been sitting picking between sleep snippet 2, 3, and 5 for every post! Good tip.

While we're at it, and if I may, what'd you do to force your side sleeping? I'm currently fighting the anti-back-sleeping fight myself. I also read your "Solving Lip Flutters" post and look at that - we came to just about the same solution, though yours is more sophisticated. I have the exact same white chinstrap you have posted there. I use it unmodified and just wrap it ear-to-ear and secure it at the back of my neck. Would definitely help to make custom velcro fasteners so I don't have such a bulky bunch of fabric at the back of my neck.

Here's tonight. Back to fixed CPAP mode: Wish I could identify this flatlining to 0 flow. Whatever this is, it's causing a bunch of my UF1 and UF2 flags. I will most certainly want to figure it out once I deal with the FLs. Looks like palatal prolapse, looks like expiratory mouth breathing (from the OSCAR flow limitations wiki page on apneaboard, which Pugsy posted on page 1). Either way, something I suspect may persist into whenever I get my hands on a VAuto. And here's what an "uninterrupted" period of breathing looks like. FLs galore. Cheers.

pineh, my responses to your post I quote from:


"The small difference between PS and EPR make me think that indeed small pressure differences make all the change, but also that the algorithm of the VAuto is superior to AutoSet for timing breaths properly and dealing with FLs."

Reply: The "if" in my earlier post reflected my long-time thought that the devices use a different algorithm, the VAuto being much more resistant to cutting pressure in the midst of the flow "noise" at the peaks. Look at the irregular Autoset pressures vs.the nearly flat curve of the VAuto. The upper pressures are for the most part about the same, but the Autoset recedes from it and then has to rebound soon.

"While we're at it, and if I may, what'd you do to force your side sleeping? I'm currently fighting the anti-back-sleeping fight myself."


My miraculous finding of that vest is detailed in a post at one or the other of two leading sleep forums. Not just serendipitous, but a miracle from God like many others, momentous or trivial in my life. Shortened long story: I was long disappointed to find myself on my back (thanks to accelerometer data graphs that showed my denial) with OSA up, after many drastic measures kept failing. I made a rare visit to a hospice thrift store looking (un-hip man my bride tells me I was re expecting to find that popular jacket) and hoping to find what I thought was commonly available: one of those Levi, heavy denim, long sleeved jackets (with metal buttons) like cattle ranchers and cowboys supposedly use. I was going to cut off sleeves and have a large pocket put on the back to accommodate a supine-block such as is pictured. I saw that red thing exposed at the end of shirts on a clothing-hanger pipe and "just happened to look at it" as I had "just happened" to go to a thrift store on that day and "just happened" to plan making the exact thing that "just happened" to catch my eye where it was. And it "just happened/happens" to be perfect for my use. the pocket is filled with two nested empty cardboard boxes from Costco. It has heavily braided nylon reinforcements along outer stress bearing edges that anchor heavy duty, large metal snap buttons, It is made from light canvas and is durable like heavy denim. My guess is it was custom made for some mountain timber or other surveyor's use.

"I have the exact same white chinstrap you have posted there."

I used that only briefly and converted to a cervical collar. A firm believer now, I was to adapt it. It's important it be high enough but not uncomfortably high or tight. I tried a lot of available straps, DIYed stuff, including one anchored to a cap with its bill cut off. I use one about 3.5 in at the chin dip and ordered a 4 in one I wore once, but it is too high.

"Wish I could identify this flatlining to 0 flow. Whatever this is, it's causing a bunch of my UF1 and UF2 flags. I will most certainly want to figure it out once I deal with the FLs."

"Looks like palatal prolapse, looks like expiratory mouth breathing (from the OSCAR flow limitations wiki page on apneaboard, which Pugsy posted on page 1). Either way, something I suspect may persist into whenever I get my hands on a VAuto."

I expanded one or two breaths of either lip flutter or PP instances to fill the whole screen and printed them. Intention was to use a planimeter to compare enclosed areas below inhale curve and above exhale curve and assess differences in light of leakage and mask design vent values. Hand is too shaky to pull coordinates off the on-screen curve using the mouse and do numerical integration. The project lingers in a stack of companions. I see a lot of PP some nights and it has not seemed like leaks accounted for them, visually that is.

I'll study your graphs more before forming any ideas re your flats. You are in good hands, I'm a novice at reading the tea leaves.

Precisely my thoughts on the autoset algorithm. Fishy at best in its apparent desire to keep the pressures climbing, only to recede back down with no improvement.

I love the picture. That's pretty bang-on what I look like at night! Bit of a monster, but a soon to be well-rested one. A vest - brilliant. Here's the solution to my backpack-stuffed-with-pillow ending up on the floor every night.
Looks like you stumbled upon treasure, indeed miraculous. Nested cardboard boxes sound like an excellent alternative to stuffing that pocket with pillows.

I've tried a cervical collar, and while it wasn't the most comfortable, the real thing is that I didn't find it to help so much. Tape did the trick to keep my jaw in place, and these days it's my cheeks blowing up with pressure (due to my suspected palatal prolapse - but who knows for sure).
So I use the white chin strap wrapped around my mouth much the same way you have your (now retired) brown mouth-strap in that picture. That seems to help a little, but clearly hasn't cured me.
I wonder if a cervical collar might do something with those flatlines. I might have to go dig it out of wherever I shoved it and just give it another ago.

I'm glad I'm not crazy in thinking hat the PP-looking flow flatlines can't be accomodated by leaks. I aim to figure this out once I get my hands on that VAuto, which might just be in a few days.

Indeed I've understood more in the past couple days of this post than I have in the last month. Glad to be here.

Update on the VAuto procurement:
Successfuly got my CPAP Rx from my Sleep Doc's receptionist, so I can now buy a VAuto out of pocket. Reason cited is traveling and need Rx for emergencies (thanks to a helpful thread on this forum). However, I also had the insane luck to be offered another appointment with him this Friday the 21st!
I'm going to beg him for a Bilevel at that appointment referencing FLs and a need for higher pressures with discomfort exhaling at high pressures. Hopefully that does the trick and saves me a good chunk of change with insurance. However, I'm thinking he may not appreciate giving me an Rx with my self-prescribed EPAP, IPAP, and PS.

I'm thinking of asking for EPAP min 6, IPAP max 13 (so as not to raise his eyebrows), and a PS of 4 or 5.

Well, had my appointment with the sleep doc.

He didn't seem concerned about the flow limits. I showed some of the ugly flow graphs and that didn't phase him.Told him I can't keep comfortable at the higher pressures and need a higher EPR.

He said there's no reason to do a Bilevel for now.

Told me to stay in AutoSet (standard, not for her), with a range of 8-13, and change my response time from "soft" to "Standard" in comfort settings and claimed that will round out my inspiratory curve. He doesn't think I need a pressure more than 10 and told me not to worry about the flow rate graphs.

Additionally told me it's nuts to go out of pocket for a VAuto. So now I'm not sure. I guess I'll give it another night with AutoSet.

I also asked for a titration. He said he doesn't think I need it, and that it would be a pain anyway with COVID tests needed (I said it's been a pain self-titrating). So I don't think that's happening.

Anyway, that's that. Back to uncertainty. I'll probably cave and pay for the VAuto tomorrow or something.

If you're patient and diligent, you can find lower hour vautos on the used market for really reasonable prices.

I had to go through similar hassles as you with my sleep doctor, and while I did get a titration study and prescription for bilevel in the end, it frustrated me enough that I ended up just buying machine and backup machine on the used market.

If I had done that to begin with, my out of pocket costs would have been lower than the traditional route with insurance.

Pardon my bumping this thread, but did you ever have any progress Pineh?

I myself have tried everything for UARS - Autoset, Vauto, ASV and all manner of experiments with cervical collars, etc blah ad nauseam.

I have recently ordered an Alaxo 6" soft palate stent, which you can place in two positions - soft palate or the NOT so well known about 1.5cm further down position to actually stent the toungue base which is demonstrated in the clinicians manual if the soft palate position doesn't provide relief from obstruction, which I believe should be an almost guaranteed fix for any case of UARS unless the epiglottis is involved in obstruction, which is incredibly rare.

After 2 years of failed CPAP (it helps me stay awake but during REM it's useless due to fragmentation and waxing/waning arousals etc) I am hoping the stent is the answer.

I own my own Resmed Airlink Home Sleep Study unit with nasal cannula so I can definitively prove the efficacy of the soft palate stent in both positions.

I'm happy to share my results here and expect to receive the stent within 2 weeks. I have already tested their 3" stents in my nasal passages to get used to things (as they were in stock) which proved pointless for therapy, although they did increase nasal breathing it did nothing to help the flow limits. The problem is very clearly further down, as are most cases of UARS.

Regards,

Pete

ppap83 wrote: ↑

Tue Jun 06, 2023 4:09 am

Pardon my bumping this thread, but did you ever have any progress Pineh?

bumping is okay.

however pineh hasn't been here in almost 2 years.