Message for Avi

Janknitz · Post by **Janknitz** » Thu Apr 28, 2011 1:10 pm

If I buy a new S9 Autoset Flow Generator only on my own for around $800 and connect it to my present rented S9 Elite humidifier (it was used when given to me) what about the 6 months rental left for the DME to charge Medicare? Will they continue to charge Medicare for it?

Nobody's forcing you to continue renting the Elite flow generator under Medicare, but you may want to keep renting it to have on hand as a backup.

And you'd probably be taking your life in your hands if you try going back to the same DME for supplies after you return the Elite flow generator.

Slartybartfast · Post by **Slartybartfast** » Thu Apr 28, 2011 1:17 pm

Avi,

I was tempted to continue the silliness about whether eating Scrapper would violate the Torah. Then I looked at your graphs again and said to meself,
'Oh . . . my . . . HECK!" which is what I heard my LDS neighbor across the street utter with some passion and ferocity when he dropped a sheet of 3/4" plywood edge-on across his toes. It was summertime and he was barefoot. I drove him to the emergency room. I've gotta say, I'll always admire that fellow's restraint in the face of adversity. You might say he's a nice goy.

Or not.

My, but that's an ugly graph. That many "centrals" and hypopneas indicate something's terribly wrong. And you've got obstructions up the ying-yang, as evidenced by the flow restrictions chart and by the flattening of your breath peaks. At the same time your lungs are signalling, "No more air, please!" which is why you're seeing all those "centrals." You're facing a heck of a dilemma. I really don't see how CPAP therapy is going to help you. Raise the pressure to open the airway and lessen the obstructions, and you'll increase the "centrals" and hypopneas for sure. Lower the pressure to lessen the "centrals" and your obstruction will get worse.

Yours is a difficult situation. Were I you, I'd RUN, not walk, to a GOOD sleep doc or Ear Nose Throat doc.

scrapper · Post by **scrapper** » Thu Apr 28, 2011 1:48 pm

Slartybartfast wrote:Avi,

I was tempted to continue the silliness about whether eating Scrapper would violate the Torah. Then I looked

I want to make something VERY CLEAR here........avi123 is asking about eating THE OSTRICH which is my avatar--a picture with a fun story from a trip to Panama a few years ago--not me, Scrapper.

Personally I am Christian-- not Kosher, and I still do not know about the ostrich. One thing I do know about the Ostrich is that he was a tough old bird, definitely of the male species.

In regards to the original post.....I'm glad avi123 that you finally see the value in an apap, even if your reasoning is twisting and wrong. The machines do have great value--and I heartily endorse them over straight cpap for the long haul.

Slartybartfast · Post by **Slartybartfast** » Thu Apr 28, 2011 2:02 pm

Ok, I thought the avatar's name was Scrapper. Subtle attempt at humor. My mistake.

Still tastes like chicken, I bet.

avi123 · Post by **avi123** » Thu Apr 28, 2011 2:22 pm

ozij wrote:No cpap - fixed or auto - will "open" an apnea. Continuous Positive Air Pressure is there to stend your airway and keep it from collapsing, but if it collapses, it collapses. With proper pressure, in garden variety OSA, most obstructive apneas will be prevented - or perhaps be shorter, but none are "opened".

You are also mistaken in assuming the Autosed will "drop the pressure" if it encounters a central apnea. It will do no such thing. After an apnea it condsider obstructive, an Autoset will raise the pressure. After a central apnea it will simply not make any changes.

You have got many flow limitations - these are going to drive the Autoset's pressure up -- in an attempt to get rid of them. The Autoset is very responsive to flow limitations.

What do your snores look like on the ResScan charts?

Reply:

Hi, reading the report by Resmed engineers which you gave a link to a couple of months ago, they wrote that the S9 Autoset will drop the pressure (to below 10 cm) if the FOT detects an open airway.

avi123 · Post by **avi123** » Thu Apr 28, 2011 3:09 pm

Slartybartfast wrote:Avi,

My, but that's an ugly graph. That many "centrals" and hypopneas indicate something's terribly wrong. And you've got obstructions up the ying-yang, as evidenced by the flow restrictions chart and by the flattening of your breath peaks. At the same time your lungs are signalling, "No more air, please!" which is why you're seeing all those "centrals." You're facing a heck of a dilemma. I really don't see how CPAP therapy is going to help you. Raise the pressure to open the airway and lessen the obstructions, and you'll increase the "centrals" and hypopneas for sure. Lower the pressure to lessen the "centrals" and your obstruction will get worse.

Yours is a difficult situation. Were I you, I'd RUN, not walk, to a GOOD sleep doc or Ear Nose Throat doc.

Reply:

Appearantly it is not chemical engineering whereby you mix something and you sure know what's the result!

Still, I don't think that my is a difficult case. Not for my age of 81. As soon as I get my AHIs to around 10, and the Centrals to around 5, and steady I'll be happy.

Six months ago I came down with a Peripheral Neuropathy (my feet soles got numb) and then the sleep fragmentation started. Thanks to Medicare I get first class physician and I am coming along nicely. Just a bit of "residual daytime sleepiness". Nothing else bothers me.

Slartybartfast · Post by **Slartybartfast** » Thu Apr 28, 2011 3:21 pm

On the one hand, you've got lots of snores and flow limitations that indicate your pressure is too low. But your events chart shows a veritable plethora** of mostly "central" events. Or at least they're non-obstructive or open airway apneas, a terminology I prefer. The predominance of non-obstructive events indicates your pressure is too high and the chemoreceptors and/or stretch receptors in your lungs are signalling your central nervous system to quit the breathing because:

Choose 1 (10 points):

A. The lungs are full.

B. The level of CO2 in the blood is acceptably low so breathing is not needed at this time.

C. Both A and B

I wonder what the S9 Autoset algorithm will decide to do when confronted with conflicting input. On the basis of the flow limitations and snores the Autoset will want to increase pressure to open up your airway. But on the basis of the "centrals" it will make no change. I suppose one of those two will win out. I suspect the algorithm is biased toward keeping the airway open at the cost of increased "centrals" so I expect it will increase pressure.

** I hear that's like the difference between a "bunch" and a "whole bunch" in Southern-speak.

Slartybartfast · Post by **Slartybartfast** » Thu Apr 28, 2011 3:43 pm

gvz wrote:I know what avi needs: Essential Fumes. Lately I've been doing well with Bacon-Flavored Fumes in my humidifier. It lowers my AHI, truly!

Yes, but bacon's DEFINITELY not Kosher. Nor is cheeseburger, nor spaghetti with meatballs and cheese, though you could leave the cheese off, or the meatballs, or both, and be OK.

Just reading this over and what MD Hosehead says is good advice. Centals, and open airway apneas aren't really bad things so long as you aren't in a periodic breathing cycle of Central Apnea --> Desaturation --> Respiratory Related Arousal --> Central Apnea in which case you'll not get any rest. Your lungs are full, your blood is fully oxygenated, or at least your CO2 level is low, which is sort of the same thing, so other than messing up an otherwise pretty graph, maybe it's not too much to get excited over. Maybe I got excited seeing all those events clustered together.

So long as a pulse oximeter says you're getting plenty of oxygen. So I second M.D.H's suggestion that I overlooked earlier. If your SPO2 level is OK while you sleep, even with all the "centrals" being recorded, you're doing lots better than you would be if your flow limitations and snoring were left untreated.

Slartybartfast · Post by **Slartybartfast** » Thu Apr 28, 2011 3:55 pm

A wee dram of barbecue sauce inthe humidifier water couldn't hurt.

avi123 · Post by **avi123** » Thu Apr 28, 2011 5:22 pm

Janknitz wrote:
If I buy a new S9 Autoset Flow Generator only on my own for around $800 and connect it to my present rented S9 Elite humidifier (it was used when given to me) what about the 6 months rental left for the DME to charge Medicare? Will they continue to charge Medicare for it?

I agree with you on this:

Nobody's forcing you to continue renting the Elite flow generator under Medicare, but you may want to keep renting it to have on hand as a backup.

But not on this b/c they are nice with me:

And you'd probably be taking your life in your hands if you try going back to the same DME for supplies after you return the Elite flow generator.

******************************************************

The DME replied: "The cost for a new S9 auto set will be $853.00 and you can use the humidifier you have now. We will still bill the remainder of the 13 month rental for the current unit you have now. No new claim will be filed to Medicare except for future supplies. Let me know how I can help!!"

Jan, thanks for helping!

avi123 · Post by **avi123** » Thu Apr 28, 2011 5:49 pm

M.D.Hosehead wrote:[quote="avi123

JMO, but I think you're making progress. Do you have an oximeter? The reason I ask, is that it's possible some of the "centrals" are not "real," especially the ones near sleep onset and awakening. If the centrals aren't accompanied by desats, you may not need to worry about them.

Many of us need more than 9.6 cm. If, in fact, you can disregard some of the "centrals," it may be no problem to go higher.

Thanks. My sleep doc who holds an MD in Pneumonolgy and an MD in Internal Medicine, says that I dont need an Oximeter b/c it will just complicate the whole issue of reading data. He also does not believe in CPAPS data accuracy b/c they rely only on Flow.

I don't worry about desats b/c in the PSG that I did six months ago the CPAP fixed it.

ozij · Post by **ozij** » Thu Apr 28, 2011 10:36 pm

at the beginnig of this thread avi123 wrote:<snip>

I am in the 6 month of rental under Medicare. My DME on its own changed the S8 Escape II with S9 Elite in the third month of rental. But my AHIs are still high and I need higher pressures to counteract the Obstructive and not burden the Centrals. My sleep doctor MD gave me an RX for an S9 Autoset. But the DME (who is Medicare provider) emailed this to me:
*********************************************

Avi

later on in this thread avi123 wrote:
Thanks. My sleep doc who holds an MD in Pneumonolgy and an MD in Internal Medicine, says that I dont need an Oximeter b/c it will just complicate the whole issue of reading data. He also does not believe in CPAPS data accuracy b/c they rely only on Flow.

I don't worry about desats b/c in the PSG that I did six months ago the CPAP fixed it.

I think you are very wise in consulting your doctor. You really should do exactly what your doctor tells you at this point, even if he does seem inconsistent at times - he may be far more consistent that it seems at first blush.

For instance, I can imagine a sleep doc who holds an MD in Pneumonolgy and an MD in Internal Medicine noting that xPAP machines are limited, because their analysis is based on flow alone, and it does not contain EEG data, nor data from chest and abdomen effort belts. But that only means they are limited. They could - in this doctor's opinion - actually be very accurate in showing flow variations and interruptions, and yet still be limited. But a patient could be unclear about the difference between "limited" and "lacking in accuracy" and cofuse those two.

Perhaps the doctor was simply telling you that flow alone doesn't give info about the state of your sleep? Perhaps he was wondering which of your central apneas are simply a result of catchup breaths, those that you take after obstructiong? Perhaps he was aware that those bad results mean your sleep is fractured? Perhaps he wants you to have an auto so you you can sleep at lower pressures until the need arises? An APAP does drop pressure if it sees you breathing smoothly for a while.

As a matter of fact, and APAP may drop too low after a time of stability - which is why one should be careful not to set the bottom limit too low.

Yes, you really should do exactly what your doctor tells you at this point.

ozij · Post by **ozij** » Thu Apr 28, 2011 10:58 pm

avi123 wrote:
ozij wrote:No cpap - fixed or auto - will "open" an apnea. Continuous Positive Air Pressure is there to stend your airway and keep it from collapsing, but if it collapses, it collapses. With proper pressure, in garden variety OSA, most obstructive apneas will be prevented - or perhaps be shorter, but none are "opened".

You are also mistaken in assuming the Autosed will "drop the pressure" if it encounters a central apnea. It will do no such thing. After an apnea it condsider obstructive, an Autoset will raise the pressure. After a central apnea it will simply not make any changes.

You have got many flow limitations - these are going to drive the Autoset's pressure up -- in an attempt to get rid of them. The Autoset is very responsive to flow limitations.

What do your snores look like on the ResScan charts?

Reply:

Hi, reading the report by Resmed engineers which you gave a link to a couple of months ago, they wrote that the S9 Autoset will drop the pressure (to below 10 cm) if the FOT detects an open airway.

One of us misread, misunderstood or misremebered what they read.

If you point to my specific post and quote the pragaraph in the report that supports your position, one of us my learn from their mistake.

Until you do so, I maintain my position: The ResMed Autoset algorithm does not reduce pressure in response to an apnea it identifies as central.

avi123 · Post by **avi123** » Fri Apr 29, 2011 8:16 am

ozij wrote:
avi123 wrote:
ozij wrote:No cpap - fixed or auto - will "open" an apnea. Continuous Positive Air Pressure is there to stend your airway and keep it from collapsing, but if it collapses, it collapses. With proper pressure, in garden variety OSA, most obstructive apneas will be prevented - or perhaps be shorter, but none are "opened".

You are also mistaken in assuming the Autosed will "drop the pressure" if it encounters a central apnea. It will do no such thing. After an apnea it condsider obstructive, an Autoset will raise the pressure. After a central apnea it will simply not make any changes.

You have got many flow limitations - these are going to drive the Autoset's pressure up -- in an attempt to get rid of them. The Autoset is very responsive to flow limitations.

What do your snores look like on the ResScan charts?

Reply:

Hi, reading the report by Resmed engineers which you gave a link to a couple of months ago, they wrote that the S9 Autoset will drop the pressure (to below 10 cm) if the FOT detects an open airway.
One of us misread, misunderstood or misremebered what they read.

If you point to my specific post and quote the pragaraph in the report that supports your position, one of us my learn from their mistake.

Until you do so, I maintain my position: The ResMed Autoset algorithm does not reduce pressure in response to an apnea it identifies as central.

Before I reply:

Please clarify this:

You wrote: "You are also mistaken in assuming the Autosed will "drop the pressure" if it encounters a central apnea. It will do no such thing. After an apnea it condsider obstructive, an Autoset will raise the pressure. After a central apnea it will simply not make any changes. "

If I set the S9 Autoset at 8 cm low and 12 cm hi, what will it do if it encounters Obstructive Apnea vs. Central Apnea?

BTW, you have a grammar mistake when you write: "Continuous Positive Air Pressure is there to stend your airway and keep it from collapsing" . IMO, the word is STENT and not STEND.

ozij · Post by **ozij** » Fri Apr 29, 2011 8:55 am

avi123 wrote:BTW, you have a grammar mistake when you write: "Continuous Positive Air Pressure is there to stend your airway and keep it from collapsing" . IMO, the word is STENT and not STEND.

Thank you for correcting my typo. You were quite correct, the word I mistyped should be "stent" and the sentnce should read:
Continuous Positive Air Pressure is there to stent your airway and keep it from collapsing. It never "blasts through" an apnea.

I wrote:No cpap - fixed or auto - will "open" an apnea. Continuous Positive Air Pressure is there to stent your airway and keep it from collapsing, but if it collapses, it collapses. With proper pressure, in garden variety OSA, most obstructive apneas will be prevented - or perhaps be shorter, but none are "opened".

You are also mistaken in assuming the Autoset will "drop the pressure" if it encounters a central apnea. It will do no such thing. After an apnea it considers obstructive, an Autoset will raise the pressure. After a central apnea it will simply not make any changes.

You have got many flow limitations - these are going to drive the Autoset's pressure up -- in an attempt to get rid of them. The Autoset is very responsive to flow limitations.

What do your snores look like on the ResScan charts?

in response avi123 wrote: Reply:

Hi, reading the report by Resmed engineers which you gave a link to a couple of months ago, they wrote that the S9 Autoset will drop the pressure (to below 10 cm) if the FOT detects an open airway.

I wrote:One of us misread, misunderstood or misremembered what they read.

If you point to my specific post and quote the paragraph in the report that supports your position, one of us may learn from their mistake.

Until you do so, I maintain my position: The ResMed Autoset algorithm does not reduce pressure in response to an apnea it identifies as central.

Instead of pointing to the report avi123 wrote: Before I reply:

Please clarify this:
<snip>
If I set the S9 Autoset at 8 cm low and 12 cm hi, what will it do if it encounters Obstructive Apnea vs. Central Apnea?

One of us misread, misunderstood or misremembered what they read.

If you point to my specific post and quote the paragraph in the report that supports your position, one of us may learn from their mistake.

Until you do so, I maintain my position: The ResMed Autoset algorithm does not reduce pressure in response to an apnea it identifies as central.

In order for this discussion to be a learning experience for me, you, or anyone else who happens to read this thread, we have to be on same page in the same paragraph of the ResMed engineers report that you refer to.

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