CPAPtalk.com

Miss Emerita wrote: ↑

Mon Apr 03, 2023 11:15 am

Be aware that in the study comparing 12 machines, the settings were wide open, at 4 to 20. And despite the fact that flow limitations was singled out as a key measure for the comparisons, there is no information provided about settings for EPR or equivalent.

True, but the response curves were radically different, and I mean radically. Trying CPAP may disabuse me of this notion, but I'd be flabbergasted if I've had the results I've had because of using ResMed's APAP algorithm. I just can't see it. But time will tell!

JOinPA wrote: ↑

Mon Apr 03, 2023 7:24 am

Still on the learning curve, but still getting great results.

I saw a video by LankyLefty on why he hates APAP and why CPAP works for most people,

CPAP cannot respond to your changing needs, from hour to hour and night to night.

I was on fixed pressure initially, and felt great, and over a period of a month, I started feeling worse and worse, and finally got around to checking my data... and my AHI had been steadily climbing for a *month*.

I got myself an APAP, and I haven't looked back, it adjusts to my needs and my AHI *stays low*.

Jason sees people on a short term basis, and is perfectly happy to have them come back ($$$) for re-evaluations.

Uncle creepo just wants you to watch his videos and buy his service (also $$$).

JOinPA wrote: ↑

Mon Apr 03, 2023 10:38 am

And, here's me getting my geek on. Interesting study.

Gonna try CPAP tonight at 12.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8836620/

Sure, you can "save money" by buying a *cheaper* CPAP instead of a *more expensive* APAP, There's nothing in that study that even HINTED that CPAP WORKED BETTER.

Are you trying to save money?

They're using CPAP to find out what the highest pressure needed was and then setting a CPAP to that.

I'd rather have lower pressures for most of the night and let the APAP raise pressure when I need it, like if I'm in REM or roll onto my back.

However, you do whatever you want to!

Wow. Just wow.

I have not been around this game as long as many of you, but I don't think I've seen more inability to address an issue logically on any board I've ever joined as I have here. I was trained as an economist, trained in logic, and am used to thinking in systematic terms. The nonsense on stilts I've seen here is simply astounding.

Palerider, did you even watch this video? Watch it, then come back and explain to me how a random APAP algorithm was the key to your success. I'm not arguing you did not get better results with it than CPAP, of course you did. But asserting that CPAP therapy needs may change as you age, gain or lose weight, other health factors in your life might change the therapy that works best for you is certainly not news. Heck, it isn't news to me even though I'm just recently working up the learning curve. Pugsy makes the most sense here, this is a very idiosyncratic topic, and one person's experience may not translate into what will work for you. Makes sense to me.

https://www.youtube.com/watch?v=v6_NHkXgSRU

"Pick any APAP algorithm, go ahead, they're all more efficacious than CPAP. Doesn't matter which one you choose!" Nonsense on stilts. I didn't argue for CPAP over APAP or the reverse, I just mentioned I was going to experiment with it. I have no clue why this dances on your last nerve. It seems to be dancing on a lot of folks' nerves here. "If you're sleeping well, don't change anything! Obviously you've found the magic elixer that solved your issue, change anything you may jeopardize that!" Again, I like Pugsy's approach to this, play around with stuff, if it doesn't work, go back to what did.

And the criticism of either of these guys because they run a business "trying to sell you something" ... that argument is not even worthy of my addressing. You wouldn't get it if I could explain the problem with that to you, and I have better uses of my time.

The article did talk about cost savings, but the important takeaways from it were that in some very statistically significant ways they found CPAP was more effective for many people (not all) than APAP. Like asking if you watched Nicko's video, I'd ask did you read the study? Do you understand statistics? Can you logically interpret what you read? There was a ton of stuff in that study that, and I quote: "HINTED that CPAP WORKED BETTER.". Yes. Yes there was, for a good number of people. I've just ticked you off my list of folks who are likely to give me scientifically-based helpful advice.

I arrived here with an open mind, wanting to learn. One thing I am learning is there is a lot of voodoo religious type stuff floating around here.

Better add me to your list in your sig, Palerider. I'd consider it a point of pride, as a matter of fact.

I'm not really interested in any more comments in this particular thread. I'll report back my findings with my experimentation for any who are interested in it. The rest of you can move on to things which interest you more. I urge you to do that. Please.

JOinPA wrote: ↑

Mon Apr 03, 2023 6:04 pm

Palerider, did you even watch this video? Watch it, then come back and explain to me how a random APAP algorithm was the key to your success.

I have no desire to watch the noise that uncle creapo create, and I'm not talking about "a random APAP algorithm, njot do I intend to waste my time talking about "a random APAP algorithm", I'm talking about the *RESMED* algorithm, the same one that I've been using, and according to your signature, that YOU are using. If indeed you understand ANYTHING

JOinPA wrote: ↑

Mon Apr 03, 2023 6:04 pm

I was trained ... trained in logic

about logic, you would see that it is ILLOGICAL to be gibbering on about OTHER MANUFACTURERS machine behavior, yet here you are.

JOinPA wrote: ↑

Mon Apr 03, 2023 6:04 pm

Better add me to your list in your sig, Palerider. I'd consider it a point of pride, as a matter of fact.

Another thing you don't understand... until you start spouting bullshit that *may harm new people*, you don't qualify.

You certainly have earned a spot on the "too stupid to talk to" list.

JOinPA wrote: ↑

Mon Apr 03, 2023 6:04 pm

The article did talk about cost savings, but the important takeaways from it were that in some very statistically significant ways they found CPAP was more effective for many people (not all) than APAP.

Yes, some people do in fact do better with fixed CPAP than with APAP: Pressure changes can bother some people. And there are even a minority of folks on this board who use fixed CPAP mode by choice because they do find that they sleep better with straight CPAP.

But as I wrote before: I don't see any real savings being accomplished by promoting "Prescribe CPAP first and only switch a patient to an APAP if they cannot tolerate CPAP." At least not here in the US.

Here's why: The insurance/Medicare billing code for all CPAP/APAP machines is the same. And a typical insurance company and Medicare/Medicaid will pay the DME the exact same amount regardless of which CPAP/APAP the DME sets up for a given patient. And the patient will pay exactly the same amount of money out of pocket, regardless of the machine they get from the DME. Hence the "savings" for setting a patient up with a CPAP (that cannot be set up to run in APAP mode) will be pocketed as profit for the DME. The insurance company (or Medicare/Medicaid) will pay the just as much money regardless of whether the patient gets a CPAP or an APAP. The patient will pay just as much money regardless of whether the patient gets a CPAP or an APAP. There is no meaningful savings for setting a patient up with a CPAP instead of an APAP; just more profit for the DME.

And now note this as well: Every APAP can be set up in CPAP mode. But no CPAP can be set up to run in APAP mode. If a patient is set up with an APAP running in CPAP mode, that patient can be switched over to APAP without replacing the machine (at additional cost).

Now factor in this as well: A number of us long time members started using PAP way back when in the bad old days when the most common machines were what are referred as "bricks"---machines that recorded no data except usage data. DMEs pushed these machines on patients specifically because the DME made more profit. But if/when things went wrong (as it does in large numbers of cases) the poor patient had no data at all to help them figure out why the PAP was not making them feel any better.

From the paper, my emphasis:
https://www.ncbi.nlm.nih.gov/pmc/articl ... 210286.pdf

Treatment was switched to CPAP in patients who met the following criteria: satisfactory adaptation and adherence to APAP, residual apnea-hypopnea index (AHI) of < 5/hour, and no relevant air leaks.

Let's emphasis:

1. satisfactory adaptation to APAP,
2. satisfactory adherence to APAP,
3. residual apnea-hypopnea index (AHI) of < 5/hour
4. and no relevant air leaks

Patients were excluded if any of the following criteria were present: poor adaptation or compliance to APAP treatment, hypoventilation disorders, a predominance of central events, cognitive disability, and incomplete medical data.

Ninety-three patients were included in the study. APAP and CPAP were both effective in correcting obstructive events and improving daytime sleepiness.

And which percentage are those 93 of the total? Of how many of those given APAP were not selected?

In a total of 209 patients with OSA undergoing APAP therapy, 93 were included based on the selection criteria.

Less than half!

The reasons underlying participant exclusion from the study were: poor APAP compliance (n = 81), residual AHI of > 5/h under APAP therapy (n = 19), associated hypoventilation disorders (n = 11), and significantly incomplete medical records (n = 5)

.
Percentage of those excluded for unsuccessful therapy = (81 +19)=100/209 = 48%


As for the aim and conclusions:

The selection of fixed-pressure CPAP through 90th or 95th percentile APAP pressure proved to be effective and an alternative strategy to titration polysomnography.

Titration polysomnography (PSG), performed in sleep
laboratories, is the gold standard approach to determine
optimal PAP levels but is associated with high costs
and long waiting lists.(7) Previous studies have shown
that the 90th or 95th percentile pressure level obtained
through APAP tracking system registration has a good
correlation with the PAP levels obtained through titration
PSG; this approach is more cost-effective compared to
manual laboratory titration.(14,15) In patients treated with
APAP, after identifying the most suitable fixed pressure
that corrects respiratory events through the 90th or 95th
percentile, it is possible to modify treatment to CPAP
using that specified level of pressure.

My emphasis
Very catchy, especially for a study conducted and published during the Corona pandemic... good for the publish or perish race.


As for the savings: This is Portugal, not the US. and the calculation wasn't based on the cost of the machine, but it's rather an attempt to calculate the savings in the cost of ongoing treatment of a chronic medical issue, in Portugal.

The mean time between the beginning of CPAP treatment and the end of the study was 22.8 ± 7.7 months. Based on the contractual costs of PAP therapy in Portugal, the transition from APAP to CPAP enabled a mean savings of 119 ± 39.11€ per patient and, at the end of this two-year study, including 87 patients who remained under CPAP treatment, an amount of 10,353.84€ was saved.

When APAPs first arrived, some sleep-medicine people reacted negatively because they were afraid "auto-titrating" treatment machines would make their jobs obsolete. That didn't happen.

Other sleep-medicine people embraced the technology whole-heartedly and then started handing out APAPs with the min left at 4, since that's how they were advertised by manufacturers to be used. That didn't work out well for all patients. That caused a bit of a backlash in some circles.

And now more recently, some personality cults on YouTube have been influenced by people who take a few anecdotes based on a few patients for whom APAP is contraindicated (such as UPPP victims who no longer have normal snores and flow curves) and take a few misinterpreted bench tests and suggest that all babies now be thrown out with the bathwater as a religious exercise against the evils of APAP. This is creating a new wave of APAP atheists and APAP agnostics.

All the while, the self-treaters on online forums mostly took a reasonable, measured, analytically well-thought-out approach and carved out a consensus middle ground for ourselves. We embraced the amazingly-effective technology of APAP but modified it by recommending that min be within 1 or 2 cm of what was needed to prevent apneas all night. This allowed all (or mostly all) to benefit from the groundbreaking technology by preventing the possible sleep-disruptions of major swings in pressure but still allowing some relief for the high-pressure needers and allowing the headroom of the untouched max (20 or 25) to be there for allergy season, colds, evenings of heavy drink and heavy meals, etc.

Are there some with unvarying needs who enjoy better sleep on straight CPAP? Sure! Fortunately an APAP allows them to try that any time they want by setting their APAP to CPAP mode.

I tend to cut the online YouTubers some slack in what they say, since they are often addressing UARSish or low-AHI people who aren't adapting to APAP because of being unusually sensitive to it. Knowing CPAP can help that issue for a few is useful info. Unfortunately, presenting that info in an engaging manner while misquoting studies to overextend the application of those rare circumstances is creating more misunderstanding than understanding these days, seems to me.

The various proprietary algorithms differ, but that is an argument for choice, not a reason to attack APAP. All the algorithms do fine for most and particularly well for a few. Feature, not a bug.

Yes, some studies have seemed to attack use of APAP, but remember, they generally define "use of APAP" as leaving the min at 4 for all. Online self-treaters tend to dismiss those studies as irrelevant and misguided and based on old notions from the early days of the APAP ads that oversold the hoped-for simplicity of applying APAP concepts responsibly for all.

End of historical tirade.

One of the biggest problems with APAP algorithm criticisms, is they are criticizing a misconfigured machine. One, where the minimum is set too low. Or worse, comparing algorithms for a machine that is set wide-open (4-20), grossly misconfigured.

That study that Nicko is commenting on, does exactly that. Comparing a bunch of algorithms for machines set to 4-20. Of course they are going to perform less than adequately.

JOinPA wrote: ↑

Mon Apr 03, 2023 6:04 pm

I have not been around this game as long as many of you, but I don't think I've seen more inability to address an issue logically on any board I've ever joined as I have here. I was trained as an economist, trained in logic, and am used to thinking in systematic terms.

Perhaps you could comment on the following logic and critical thinking skill.

JOinPA wrote: ↑

Mon Apr 03, 2023 6:04 pm

Palerider, did you even watch this video? Watch it, then come back and explain to me...

JOinPA wrote: ↑

Mon Apr 03, 2023 6:04 pm

I'm not really interested in any more comments in this particular thread.

Specifically, asking someone to watch a video, then comment.
And then in the very same post, stating you're not interested in comments.

Very logical.

lazarus wrote: ↑

Tue Apr 04, 2023 1:06 pm

End of historical tirade.

Who are you, and what've you done with lazarus? that's not NEARLY wishy washy enough to be from him.

Actually, now that I think about it... maybe you should stick around.

Dog Slobber wrote: ↑

Tue Apr 04, 2023 1:38 pm

Very logical.

Very something, but I don't think Spock would approve.

palerider wrote: ↑

Tue Apr 04, 2023 11:42 pm

lazarus wrote: ↑

Tue Apr 04, 2023 1:06 pm

End of historical tirade.

Who are you, and what've you done with lazarus? that's not NEARLY wishy washy enough to be from him.

Actually, now that I think about it... maybe you should stick around.

Darn. And I was really trying my best-est to make that post my wishy-washiest post ever. Major fail!!

Oh well. There's always next time.

lazarus wrote: ↑

Wed Apr 05, 2023 8:34 pm

palerider wrote: ↑

Tue Apr 04, 2023 11:42 pm

lazarus wrote: ↑

Tue Apr 04, 2023 1:06 pm

End of historical tirade.

Who are you, and what've you done with lazarus? that's not NEARLY wishy washy enough to be from him.

Actually, now that I think about it... maybe you should stick around.

Darn. And I was really trying my best-est to make that post my wishy-washiest post ever. Major fail!!

Oh well. There's always next time.

Keep trying, you'll get there, maybe, or you won't, maybe. I'm not really sure, magic 8 ball says "signs uncertain, ask again later".

Well, finally quit fiddling around, and stuck with APAP. CPAP was not meaningfully different for me, but APAP seems to be more comfortable. I respond well to both, but slightly better to APAP, perhaps because I, uh, drink too much. Anyway, on CPAP at 12, 12.5, or 13.0 my AHI range was 1.0 - 1.8. On APAP on my original setting of 10-14 my AHI range is 0.2 - 1.0 typically. Averages around 0.4-ish

One thing I learned here is what the settings actually do and I enjoyed experimenting, i.e., playing with them a bit. @dogslobber, I didn't articulate about not wanting comments very well, but that's my fault--it's up to the communicator to make himself understood, not up to the hearer to read minds. What I meant was no more comments about not experimenting. There were several that seemed to say, "Don't mess with anything, you're doing well, don't screw it up!" I didn't see any danger in playing with settings because I could always go back to the original settings, I didn't want any more admonitions about not playing with settings, but did not make that clear. Some around here are all about experimenting, some seem to viscerally against it, perhaps because they had trouble adapting until they got it dialed in correctly for them? I don't know, the why of that, but I've always responded well to PAP, so I was curious to experiment.

The end result is I am better informed about what is going on from learning here and I did make a couple changes, not to pressures, but to comfort settings. Where I settled was on APAP 10.0-14.0 but added EPR of 2 and changed Response from Standard to Soft. And I got a ClimateLine tube and use Auto for climate settings. I am loving all of this. Last night's chart here:



I'm done, and am going to quit my fiddling and enjoy my sleep. Oh, and I got my prescription and got my new ResMed AirSense 10 Card to Cloud machine on the way. My understanding is the ResMed AirSense 11 did not change the firmware much, if at all, but the blower motor went from the larger AS10 to the smaller one used in the AirMini, which I also own. I wanted to get the larger AS10 for a replacement before supplies ran out. So, I'll relegate my current machine to reserve status at a little over 17,000 hours and hopefully have nearly a decade of use out of this model ahead of me between the new and old one.

One other thing I find curious here is the negative reaction to LankyLefty or the Australian guy. Why their being entrepreneurial and running a side gig using their professional expertise taints their opinions I just do not understand. Yeah, LankyLefty used to say no special cleaners needed and now is all about the Mask Bright stuff, but I'm smart enough to ignore that. His running an analysis biz doesn't bother me, either, as I don't need it, but I bet some folks who have trouble adapting to PAP therapy are very glad for it. Anyway, they've been a great learning resource for me, I don't understand the animosity of some to their content. Anyway, thanks to all who helped me learn how this stuff works! I was fine to begin with, but I feel more knowledgeable, and I like using the EPR setting very much.

JOinPA wrote: ↑

Fri Apr 07, 2023 8:48 am

One other thing I find curious here is the negative reaction to LankyLefty or the Australian guy. Why their being entrepreneurial and running a side gig using their professional expertise taints their opinions I just do not understand. Yeah, LankyLefty used to say no special cleaners needed and now is all about the Mask Bright stuff, but I'm smart enough to ignore that. His running an analysis biz doesn't bother me, either, as I don't need it, but I bet some folks who have trouble adapting to PAP therapy are very glad for it. Anyway, they've been a great learning resource for me, I don't understand the animosity of some to their content. Anyway, thanks to all who helped me learn how this stuff works! I was fine to begin with, but I feel more knowledgeable, and I like using the EPR setting very much.

I think much of the negative reaction to LankyLefty and Uncle Nicko is that they come across to a lot of folks here as proselytizers: They are both so sure of themselves that they not particularly welcoming to folks with different opinions. And, when Uncle Nicko has been called out for actual factual errors over on SleepHQ, he's been known to ban users rather than acknowledge that he's made a mistake.

I'm glad your experiments demonstrated to you what you were looking for without creating any problems with your sleep. Some of us have to be super, super cautious about experimentation specifically because our sleep remains fragile for reasons unrelated to sleep disordered breathing and PAP therapy, and we don't want to introduce more variables that could break the system that allows us to get decent sleep.