Need Resmed education

Velbor · Post by **Velbor** » Mon May 11, 2009 2:46 pm

What Carbonman is planning to do, I am already in the process of doing. He started with Respironics, and is planning to try ResMed. I have been using a ResMed AutoSet Vantage since 2004; a bit over a year ago (before anticipated price increases) I bought a Respironics M-Series, and have just recently started to use it regularly.

I have already posted data about my ResMed experience at viewtopic.php?f=1&t=37954 under the title “AutoPAP, Activa, UMFF and Mouth Taping”. From one perspective it is "live" data, comparing results using different masks. In another sense it is "baseline" data, since I will be replicating much of the material using the Respironics.

My information will probably not answer jnk's very good questions, since I'm not looking at information on an event-by-event and "stimulus-by-stimulus" level. While -SWS' discussion makes this a tempting undertaking, I am not at this point prepared to undertake such a "granular" assessment.

Also, I will not at all be addressing "Flex" vs. EPR issues. Too many variables. And I have never needed them, and I have never tried them. An appalling lack of curiosity.

It will be a number of weeks before I have enough data to begin a meaningful post involving Respironics data, but it will include "very careful" comparisons of the two brands. I am having to be very careful in my thinking, remembering that the efficacy "numbers" generated by each machine cannot be directly compared to the other for determining which is working "better": numbers with the same titles are still apples and oranges. Pressure and time, though, should be directly comparable.

Very preliminary information at which I will only just hint now: Under identical conditions:
---the efficacy numbers are quite different. Not much of a surprise.
---pressure profiles over time are different. A bit of a surprise.
---one machine is running at much lower overall pressures than the other. A moderate surprise.
---one machine occasionally goes to much higher pressures than the other. A considerable surprise.
---event patterns seem to differ: e.g. one machine routinely calls apneas just before I awaken, the other doesn't. (Am I awakening due to apnea, or am I awakening first and therefore breathing differently? No way to tell.) Quite a surprise.
---one mask elicits much more Vibratory Snore on the Respironics than does another. A major surprise.

Thanks to everyone for their discussion here. Velbor

robertmarilyn · Post by **robertmarilyn** » Mon May 11, 2009 3:24 pm

Velbor wrote: Also, I will not at all be addressing "Flex" vs. EPR issues. Too many variables. And I have never needed them, and I have never tried them. An appalling lack of curiosity.

Hopefully we all have our limits about how obsessed we are going to be about all things XPAP

Very preliminary information at which I will only just hint now: Under identical conditions:

A teaser!!!

Thanks to everyone for their discussion here. Velbor

Thanks for what you are doing. Even though we can't do double blind studies with control groups and placebos and all, I find it very interesting to read the observations and tests that you all run. Reading about the results often gives me a much better understanding of the subject (whether masks or machines or whatever).

dsm · Post by **dsm** » Mon May 11, 2009 3:30 pm

jnk wrote:This is an interesting discussion. But it raises questions in my mind.

I wonder if using one brand's estimates of events with its definitions, detections, and reactions are easily applicable to how another brand might, or might not, have defined, detected, and reacted. Don't different brands define, detect, and react to precursors differently? If so, isn't it very difficult to guess what different brands would do in different situations based on the detections, definitions, and reactions of one brand for one person on one night with no PSG data to know what really happened, let alone what would have happened?

For example, isn't it impossible to know whether another brand would have been riding at a higher baseline pressure to start with, in reaction to it's detection and reaction to precursors, and would thus have prevented all the events in the chart, or if it would have been riding at a lower pressure based on its interpretation of precursors and then had many more events to contend with, or ignore, as the case may be? And wouldn't the question of whether either brand's estimates of events would accurately report what wasn't prevented be a further complicating factor?

Are there many well-documented cases of specific patients who were served well by one auto machine and not served well by another machine? And wouldn't applying that further than that one patient then require a very costly study attempting to get a representative cross-section of population and then weeks inside a fully-equipped PSG lab to make meaningful comparisons based on a standard that would lead to useful conclusions?

Doesn't the AASM consider UPPP to be a contraindication for using an auto at all? If so, is Mar's example applicable to the discussion at hand other than as a graphical demonstration of someone who may not be well served by any brand's auto?

This is very interesting, and I look forward to further discussion on it.

JNK

Interesting line of thinking.

One reality for me was that over a period of 6 months I swapped between a Respironics Auto & a Resmed Auto (S7 Spirit). This was back in 2005 (IIRC) and I commented on these findings here (but got no reaction). What I noticed absolutely and consistently was that on the Respironics I would get say 4.0 AI & 0.2 HI then under similar circumstances with a Resmed would get 0.3 AI & 3.6 HI - a consistent pattern of reverse AI - HI scores.

The data I kept repeatedly coming up with was that Respironics scored AIs higher than the Resmed & HIs lower. The Resmed kept scoring in an opposite pattern. When this 1st happened I naively thought these machines were, well, sort of infallible, by that I mean, accurate. My ultimate reaction was kind of a shock, that two different brands of machines could give essentially reverse readings. I had thought of these machines as FDA approved medical devices that had some reliable scoring system. Turned out I was dreaming !.

So today I believe my test could & should be repeatable by anyone. And what it reinforces for me is that as you say, without accurate data the graphs are at best a simplistic guide to somone's breathing through the night as interpreted and presented, rather inaccurately, by at times questionable software, but close enough to be a useable guide. I have always said since, that a night's data from brand x or y is relative. By this I mean relative to the model & brand & typically questionable when put up against another brand.

DSM

dsm · Post by **dsm** » Mon May 11, 2009 3:44 pm

robertmarilyn wrote:
dsm wrote:SWS
Thanks for that, makes sense, but, you didn't mention flattening & that is where I understand A10 will raise pressure if flattening is showing a repeated restriction that doesn't score as Hyp or Apnea. Resmed makes a big issue of monitoring the flattening & indexing it.
DSM
This is probably the night that -SWS is talking about (I have more examples of other nights):

<snip>

Want an opinion as to how to bring that under control

Raise pressure by just 1.0 CMs (the LOWEST you want to see is 10 CMs ) and am willing to bet the AIs & esp HIs drop away significantly (it may take 1.5 CMs increase, but am sure 1.0 would do it)

DSM

(that patter looks sooo familiar )

robertmarilyn · Post by **robertmarilyn** » Mon May 11, 2009 4:22 pm

dsm wrote:
robertmarilyn wrote:
dsm wrote:SWS
Thanks for that, makes sense, but, you didn't mention flattening & that is where I understand A10 will raise pressure if flattening is showing a repeated restriction that doesn't score as Hyp or Apnea. Resmed makes a big issue of monitoring the flattening & indexing it.
DSM
This is probably the night that -SWS is talking about (I have more examples of other nights):
<snip>
Want an opinion as to how to bring that under control
Raise pressure by just 1.0 CMs and am willing to bet the HIs drop away significantly (it may take 1.5 CMs increase, but am sure 1.0 would do it)
DSM
(that pattern looks sooo familiar )

I don't want to hijack this thread and make it about me so if we need to do so, we can take this over to my "I'm so tired" thread but at the same time, since this is a Resmed machine and this is the Resmed education thread, maybe this will be ok here...just let me know if my 'stuff' gets off topic for this thread.

I was on straight CPAP at a pressure of 14 for one week. But the machine was the Escape II and I was locked out of changing/seeing anything so I can't tell you what was going on numbers-wise. But I can tell you I was in a great deal of pain at a pressure of 14. I was dealing with major acid reflux and aerophagia during that week (bile entering my throat while I slept and not being able to stand up straight for hours after I got up each morning...boo hoo...the honeymoon was over before it started for me and CPAP ). My referral doctor told me I'd "just have to get used to it" when I mentioned it to her and my sleep doctor said the aerophagia couldn't be happening unless I was swallowing air while I was running or eating . The sleep doctor did swap my machine out for the Autoset II, which I was locked out of in every way. It was set on 4 through 17 so I immediately came here and found out how to change that

Got the software a few days later. Just now, I looked through my Rescan info to see if I had set my machine at 13 in the past but don't see where I have done that. Oh, I went to a gastro doctor and had an Upper Endoscopy to check things out concerning the aerophagia, acid reflux, and the state of my LES...didn't have any tests done specifically on my LES but the doctor mentioned that I might need to take some meds or have a procedure to help the LES tighten up. Right now I seem to be doing pretty good on acid reflux meds and keeping the pressure in the low 12 range.

I hesitate to move up from 12.2 to 13.7 (the upper 1.5 range you mentioned) in case that gets me back into the 'hurting zone'. Rather than even moving up the pressure a whole 1cm I could move it to 13 (.8 cm) and see what happens. There could be a chance it might be too much pressure for my LES to handle though.

I realize it is not the fault of the Resmed or any machine if my body can't handle the pressure I need (like if 13.5 would be perfect for me except that my LES isn't able to handle the pressure). I don't think my UPPP could have had any impact on my "loose" LES...instead I think I just came that way...no expert on this though

mar

dsm · Post by **dsm** » Mon May 11, 2009 4:36 pm

Mar,

Then as an alternate drop EPR by 1 (to 2 ) I think that may achieve the same effect.

Also are you on any GERD meds (I am daily pariet). I am though about to get a specialist referral to discuss this operation where they say they can repair the valve at the top of the stomach that allows the leakage to occur.

GERD and weight combined will mess up cpap therapy well & truly.

Good luck with this.

DSM

robertmarilyn · Post by **robertmarilyn** » Mon May 11, 2009 4:58 pm

dsm wrote:Mar,
Then as an alternate drop EPR by 1 (to 2 ) I think that may achieve the same effect.

Ok, I'll make that change tonight...and see how things go over the next week. I have the epr on 2 right now so I will try dropping it to 1 instead.

Also are you on any GERD meds (I am daily pariet). I am though about to get a specialist referral to discuss this operation where they say they can repair the valve at the top of the stomach that allows the leakage to occur.

So you understand my pain then

Share with us what you learn about the operation. That was mentioned in reference to me and my problem. Also mentioned on the impression section of the endoscopy report that I got right after the procedure was done, was that if Prilosec doesn't work that GES (an implant under the breastbone that would provide electrical stimulation to the LES to encourage it to tighten) would be considered or a trial of Reglan...my mom told me that if I took Reglan I WOULD get Parkinsons... I don't always believe every dooms day thing my mom tells me (and she tells me a lot) but from what I did read about Reglan, it could possibly have some serious and permanent side affects so I would want to carefully consider the entire picture before I made a decision to take it. Of course, I would want to learn more about having a GES and the implications before I would consider doing that also.

I'm on Prilosec at the moment but my follow-up doctor's appointment is on May 19 and the med will probably be changed to one of the other meds (that work better and do more) after my appointment.

GERD and weight combined will mess up cpap therapy well & truly.

I never knew I had GERD before but that is what the doctor is saying I have now. I'm slender and fit, in fact I always have been and have had doctors tell me I "don't fit the profile" all my life about the various things that I DO have (like sleep apnea). But yeah, I can see that GERD takes a lot of options out of XPAP therapy if the GERD cant be treated.

Good luck with this.
DSM

Thanks and you too Oh yeah...Resmed, to keep this on topic

dsm · Post by **dsm** » Mon May 11, 2009 5:33 pm

Mar

I weigh in at 84 KG at the moment (184 lbs) & my RT originally predicted I would get a clean bill of health before my 1st PSG when I weight around 198 lbs. He was wrong - had AHI of 40). But if I leave out the Pariet tablet in the morning, I start to notice the negative side effects my middle of the day. Prior to pariet I would go through about 1-2 bottles of Gaviscon per week.

DSM

ozij · Post by **ozij** » Mon May 11, 2009 6:34 pm

Titration Efficacy of Two Auto-Adjustable Continuous Positive Airway Pressure Devices Using Different Flow Limitation-Based Algorithms
Katrien B. Hertegonne Bart Rombaut Philippe Houtmeyers Georges Van Maele Dirk A. Pevernagie
Respiration 2008;75:48–54

BACKGROUND: Auto-adjustable continuous positive airway pressure devices are widely used in titration procedures to determine therapeutic pressure levels in obstructive sleep apnea patients. However, differences in operational characteristics may influence the effect on the apnea-hypopnea index (AHI). OBJECTIVES: We compared the titration performance of two devices based on detection of inspiratory flow limitation, i.e. the Respironics REMstar Auto (RR) and the ResMed Spirit (RS). METHODS: Fifty obstructive sleep apnea patients were recruited for a double-blind randomized crossover trial. Both devices were employed overnight by means of split-night polysomnography. The primary outcome was the AHI. Secondary outcome measures were the snoring index, pressure profiles and subjective appraisal of sleep quality assessed the morning after the sleep study.

-SWS · Post by **-SWS** » Mon May 11, 2009 7:07 pm

I personally don't mind side discussions such as Mar's ... especially since I'm working late with client work right now... So I'm only popping in briefly once again.

Carbonman, please pass the monkey butt powder to jnk for dropping that motherload/gauntlet of rhetorical questions that I really don't have time for right now. But Jeff's questions are so good, I personally think they're worth folding into this discussion in no small way.

Jeff, I think some useful APAP comparisons and conclusions can, indeed, be drawn. Doesn't that goal more or less parallel interpretive art often employed by science? Think of doctors executing the art of medicine when the science of medicine lacks a certain necessary robustness. Think of fuzzy logic in neural networks factoring both crisp rules and fuzzy associations toward decision making.

So I'll attempt to justify my tentative conclusions as I micro-analyze and macro-analyze my way through carbonman's charts.

Bench Evaluation of Flow Limitation Detection by Automated Continuous Positive Airway Pressure Devices
Frédéric Lofaso, MD, PhD; Gilbert Desmarais, PhD; Karl Leroux; Vincent Zalc; Redouane Fodil, PhD; Daniel Isabey, PhD; and Bruno Louis, PhD
CHEST August 2006 vol. 130 no. 2 343-349

Slinky · Post by **Slinky** » Mon May 11, 2009 7:09 pm

Thanks, Ozij. Actually, I think I have to scare up RestedGal to find an abstract/article that I remember reading & thought I bookmarked (but obviously didn't) comparing THREE manufacturer's APAPs. Actually, I think the article was not so much about comparisons between the three but rather more about the efficacy of the APAPs, maybe, probably, vs PSG in which the results did provide some comparisons between the three brands and I'm pretty sure that Puritan Bennet was the third manufacturer and that the PBs and Respironics were more "in tune" w/each other w/the Resmed somewhat set apart but the difference not considered to be of any significance.

dsm · Post by **dsm** » Mon May 11, 2009 7:16 pm

Ozij

A very interesting report. More interestingly it gives an edge to the Respironics at lower pressures but says the machines were pretty well equal at higher pressures - this is where I understand SWS is say he believes the Respironics algorithm performs better (higher pressures over 10 CMs)- So, this study says they are on a par but does say the Respironics had a slight edge in amount of REM sleep. I think that point has been made in various ways by a number of people over time. I see too that the Resmed AHI is scored higher allowing that as we often discuss, the Resmed scoring tends to give higher HI values than the Respironics.

In balance the report is saying that the Autos are enough on a par for there to be no big issues between the therapy delivered. It does lean towards the Respironics in both REM & in patient preference.

Thanks for the link.

DSM

-SWS · Post by **-SWS** » Mon May 11, 2009 7:26 pm

dsm wrote: this is where I understand SWS is say he believes the Respironics algorithm performs better (higher pressures over 10 CMs)-

That's not at all what I believe. And it has never been what I believed.

dsm · Post by **dsm** » Mon May 11, 2009 7:27 pm

-SWS wrote:I personally don't mind side discussions such as Mar's ... especially since I'm working late with client work right now... So I'm only popping in briefly once again.

Carbonman, please pass the monkey butt powder to jnk for dropping that motherload/gauntlet of rhetorical questions that I really don't have time for right now. But Jeff's questions are so good, I personally think they're worth folding into this discussion in no small way.

Jeff, I think some useful APAP comparisons and conclusions can, indeed, be drawn. Doesn't that goal more or less parallel interpretive art often employed by science? Think of doctors executing the art of medicine when the science of medicine lacks a certain necessary robustness. Think of fuzzy logic in neural networks factoring both crisp rules and fuzzy associations toward decision making.

So I'll attempt to justify my tentative conclusions as I micro-analyze and macro-analyze my way through carbonman's charts.

Bench Evaluation of Flow Limitation Detection by Automated Continuous Positive Airway Pressure Devices
Frédéric Lofaso, MD, PhD; Gilbert Desmarais, PhD; Karl Leroux; Vincent Zalc; Redouane Fodil, PhD; Daniel Isabey, PhD; and Bruno Louis, PhD
CHEST August 2006 vol. 130 no. 2 343-349

SWS,
I believe the older report you linked to does claim the Resmed device was better at detecting and responding to FLFCs which has been the point I have been making re their (Resmed's) claims about their expertise in this area. But, the tests mentioned go back far enough that I can believe both machines can have improved since then.

I sure don't believe Respironics & Resmed have not improved both their hardware (blowers sensors etc:) & algorithms to some distinct degree in the past 6 years.

Thanks for that link.

DSM

dsm · Post by **dsm** » Mon May 11, 2009 7:29 pm

-SWS wrote:
dsm wrote: this is where I understand SWS is say he believes the Respironics algorithm performs better (higher pressures over 10 CMs)-
That's not at all what I believe. And it has never been what I believed.

I apologize if I got this wrong. I really was sure you had several times made a case that the RR algorithms responded better over 10 CMs ?

Perhaps I inferred it from the way you stated it - if so again my apology.

DSM

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