APAP Related Questions and Advice

So, ever since I was diagnosed with Sleep Apnea, I've lusted for an APAP. I love the concept of only delivering the pressure that you need. Hubs is a CPAP user and I thinks I'm crazy and I should just be happy with my CPAP. He also thinks that I shouldn't adjust my own pressure, but should visit a doctor for that. Whatever...

Anyhow, my current CPAP is just a rental. Since I may be losing my health insurance in a couple of months, I'm in the market for a new xPAP. Obviously, I want an APAP. I figure worse case scenario is that I would end up using my APAP in CPAP mode.

Do either of PR System One APAPs adjust to treat snoring like the S9 Autoset does? I kind of want the S9, but I already have a humidifer that I could use with the older System One APAP. I'm trying to see if there are any reasons to justify the S9 Autoset over the older PR System One APAP.

Are there any technical advantages for either the S9 or the new PR APAP? Any other advice would be greatly appreciated.

Despite an AHI that is almost always below 3, my vibratory snore and RERA numbers are generally pretty high. My sleep is also generally pretty fractured. I wake up a couple of times a night, but I just don't get up. So, really, I'm still looking for what works for my sleep apnea.

Just 2 thoughts..
The S9 doesn't score RERA's.
If you are buying out of poscket, S9's seem to pop up for sale here more often than PRS1's.

I understand your "lust", and would certainly get an apap. Remember, (Pugsy... look the other way for a minute) it takes time for an apap to ramp up and treat an apnea. Some folks here say its the best since sliced bread. I feel better when I use cpap mode. A lot of folks here use the apap mode and are happy and feel great. It's all personal preference and comfort. Everyone should see what is best for them. Just sayin'

Sheriff

fumbling34 wrote: Do either of PR System One APAPs adjust to treat snoring like the S9 Autoset does? I kind of want the S9, but I already have a humidifer that I could use with the older System One APAP. I'm trying to see if there are any reasons to justify the S9 Autoset over the older PR System One APAP.

Both the older Series 50 System One APAP and the newer Series 60 System One APAP increase pressure in response to snoring---at least if the pressure level is less than 16cm. I believe I've seen reports that the quit recording and responding to snoring once the pressure reaches 16cm though.

fumbling34 , I am glad to see that you're using the nasal Blue mask which is similar to my mask. IMO, Resmed is using in its APAP machines, sophisticated inventions for treatment of snoring, events, and leak compensations, that no other APAP on the market has been using yet. Since I started to use an S9 Autoset in the APAP mode and the combination of the nasal mask and a chinstrap, about 6 months ago, my treatment results improved unbelievably. See here my recent RsScan Stats for a full 30 days:




Add: sometimes the APAP is "misbehaving". In the following graphs the APAP did boost the pressure up correctly to the max setting after encountering a few obstructive apneas (in red), but did not lower it fast enough after encountering the next central apnea (in black):




I think that my graphs are "skewed" (the events graph is not synchronized with the waves graph).

avi, did you make any other changes that could have influenced your result - changed medications, started/stopped using the humidifier, pressure relief, ramp, etc? The question we all should be asking is whether the only masks we use should be those manufactured by the maker of our machines? I noticed a reduction in AHI when I stopped using C-Flex Plus, and just use C-Flex. I noticed a reduction when I changed to a pillows mask (after I got the leaks sorted out. I have noted slight reductions when I do other things, so my thoughts are that any machine + any mask worn correctly = good AHI (all other things being equal). However, others may have had different experiences. I need another 2 years of use out of my machine (although I have changed insurance companies, so maybe that rule doesn't apply?), but I would vote for an APAP next time around for myself. Whether I get a Resmed, another PR, an F-P, or a DeVilbiss is a big unknown at the moment.

SleepyToo, the main changes that I did to come up with better treatment was to stop using a full face mask and instead use a plain nasal mask and a chinstrap, and use an APAP. As to medications, I don't think that it made the difference. During the last few months I started to take 0.5 mg Alprazolam ER (generic Xanax) and 300mg of Gabapentin (generic Neurontin) before going to bed.


My stats from about a year ago while using FF mask and S9 Elite CPAP:





See here 30 days Stats from about 6 mos ago when I was on F&P #431 or #432 FF mask and on the S9 Autoset but in CPAP mode:

Lizistired wrote:Just 2 thoughts..
The S9 doesn't score RERA's.
If you are buying out of poscket, S9's seem to pop up for sale here more often than PRS1's.

Thanks for the feedback! Wow! Is there a reason that the S9 does NOT score RERAs? Aren't RERAs important, too ,when trying to diagnose/fine tune any sleep issues?

avi123 wrote:fumbling34 , I am glad to see that you're using the nasal Blue mask which is similar to my mask. IMO, Resmed is using in its APAP machines, sophisticated inventions for treatment of snoring, events, and leak compensations, that no other APAP on the market has been using yet.

Avi--

It's awesome that you found therapy machine/mask sweet spot. It's definitely something for which I'm still looking. Can you clarify when you talking about the sophisticated technology that Resmed is using that other APAPs aren't using yet? Since price between the two APAPs isn't hugely different and I can use flex spending dollars if I buy soon, I honestly just want the best APAP that I can buy. Since I just found out that the S9 doesn't score RERAs, I'm kind of leaning twoards the new PR APAP.

Thanks!

fumbling34 wrote:

Lizistired wrote:Just 2 thoughts..
The S9 doesn't score RERA's.
If you are buying out of poscket, S9's seem to pop up for sale here more often than PRS1's.

Thanks for the feedback! Wow! Is there a reason that the S9 does NOT score RERAs? Aren't RERAs important, too ,when trying to diagnose/fine tune any sleep issues?

I've read in a few places that Flow Limitations, RERA and UARS are all more or less synonymous. S9 does report Flow Limitations. Someone linked to this 3 year old video clip recently. Is there some subtlety that I'm missing?
http://www.youtube.com/watch?v=JWm7tT-Z ... re=related

Sheriff Buford wrote:Pugsy... look the other way for a minute) it takes time for an apap to ramp up and treat an apnea.

Hey, I almost missed this. You are right that APAP machines need a bit of time to respond to event precursors BUT as long as the minimum pressure gives the machine a good enough head start then it has the time. They respond to event precursors and not frank out of the blue apneas. If an event sneaks past the defenses the machine sits by and twiddles its thumbs till the event passes. None of them will respond and act like a ventilator (unless ASV machine) so it doesn't matter about the response time. They could also happen when using straight cpap pressure.
The whole idea with APAP is adjusting pressure due to event precursors (snores, flow limitations, etc) and preventing a full blown event and not so much blowing through the event once it does grow up to become a full fledged apnea event.

fumbling34 wrote:Is there a reason that the S9 does NOT score RERAs? Aren't RERAs important, too ,when trying to diagnose/fine tune any sleep issues?

Respironics decided to score them and ResMed decided not to score RERAs. Don't know why either one made the choice they did.
If this is a piece of data that is important to you then stay with a machine that offers that particular data. Resmed does at least report Flow limitations even though it doesn't give you the same data point for comparison.
I do understand the lust for the S9 Autoset though and if you can find a good deal on one you might want to satisfy the lust craving. If your RERAs are really low on the PR S1 machine...it doesn't really matter if the S9 scores them or not because it would be a low number anyway.
Your choice on how important that piece of data happens to be to you.

fumbling34 wrote:

Lizistired wrote:Just 2 thoughts..
The S9 doesn't score RERA's.
If you are buying out of poscket, S9's seem to pop up for sale here more often than PRS1's.

Thanks for the feedback! Wow! Is there a reason that the S9 does NOT score RERAs? Aren't RERAs important, too ,when trying to diagnose/fine tune any sleep issues?

In Resmed S9 machines the RERA's (and the UARs) are included in the Flow Limitations which the machines treat vigorously and report in a graph. Notice that ALL the data that you see as reported from an XPAP are those that the machine has NOT treated properly. So if I had in my sleep study diagnosis night in a clinic an AHI of 45 and now I see the data given by the S9 Autoset or S9 Elite an AHI of 1.0 it means that the machine took care of lots of events, snore, flow limitation, etc.


Thanks to my APAP, the flow limitation in the following graph remains low. I am not interested to see tabulated RERAs that were not treated. What are you going to do if you saw that your RERAs are hi? Jack up the pressure which the S9 Autoset may decide to do after going thru several other calculations of the respiration wave shape?

My flow- limitation graph:

I have an example from last night of what looks like an event that was not scored by my ResMed S9 Auto. On the right is a CA event that did get scored. The red arrow on the left side points to what looks very similar (to my eye) to the event that was scored, but this earlier one was not scored -- maybe it's a teensy bit shorter in duration? This is likely some type of clear airway 'event' since no flow limitation is seen and the pressure did not go up. But it looked to me like a good example of how respiration disruptions can happen and not be scored by the machine.

Mis flagging and skewness by the S9 Autoset:

BasementDwellingGeek wrote:

fumbling34 wrote:

Lizistired wrote:Just 2 thoughts..
The S9 doesn't score RERA's.
If you are buying out of poscket, S9's seem to pop up for sale here more often than PRS1's.

Thanks for the feedback! Wow! Is there a reason that the S9 does NOT score RERAs? Aren't RERAs important, too ,when trying to diagnose/fine tune any sleep issues?

I've read in a few places that Flow Limitations, RERA and UARS are all more or less synonymous.

Yes, they're related, but the terms flow limitation (FL),respiratory effort realed arousal (RERA), and upper airway resistance syndrome (UARS) are not synonymous.

A flow limitation is a change in the shape of the inspiratory part of the wave flow data that records the movement of air into and out of your lungs. FLs are thought to be caused by changes in the airway just as it is starting to collapse or partially collapse. Informally one can think of OAs, Hs, and RERAs as "extreme" examples of flow limitations. But one can also have flow limitations that are minor enough to not result in an OA, H or a RERA actaully happening.

Both Resmed and PR APAPs record and respond to flow limitations. But the two companies have chosen very different ways to present this information when the data are downloaded into a computer. Resmed presents the flow limitation data as a continuous graph where the horizontal axis measures time and the vertical axis measures the severity of the flow limitation. (What the heck the units are on that flow restriction axis is anybody's guess.) PR records flow limitations as discrete events with an FL flag superimposed on the wave form at the place where the flow limitation was detected. (What the heck the exact criteria for scoring a flow limitation is appears to be a "trade secrete" since it is not clearly specified on any of the PR webpages that I can find.) Is one of these two methods of displaying flow limitation clearly superior to the other? Probably not. But most of us will probably develop a preference for the way FL data is displayed on our particular machine just because it becomes "the familiar way" of looking at this data.

A RERA on a sleep study is scored when there is evidence of increasing respiratory effort (as measured by the belts) with some evidence of a flow limitation that ends with an EEG arousal. No EEG arousal means no RERA can be scored. And this presents a real problem for designing a CPAP/APA algorithm for detecting RERAs. Resmed at present does not claim to have a working algorhitm for RERA detection, and hence Resmed chooses to not score RERAs. PR has an algorhithm that they believe is reliable enough (from a statistical point of view) to market as a RERA detection algorithm. Since the PR machines (obviously) do not record EEG data, the RERA algorithm must be based on statistically examining the wave flow data from a very large number of RERAs scored on PSGs and looking for characteristics that are highly correlated with real RERAs. In particular, it is clear from looking at PR wave forms with RERAs scored that the PR RERA[detection algorithm looks for evidence of a flow limitation that ends with a "recovery breath"---a breath that has a larger (and steeper) inspiratory bump followed by a return to more normal night time breathing. Are these events real RERAs? Its my humble guess as both a patient and a mathematician that many (even most), but not all, of the things the PR System Ones score as RERAs probably are real RERAs. And the algorithm probably also misses some real RERAs as well.

UARS is one of a number of conditions that broadly fall under the category of sleep disordered breathing (SDB). OSA is another diagnoses that is part of the SDB category. There is some controversy about whether UARS actually is a disorder, whether it is just one end of the OSA spectrum, or whether it is a distinctly different disorder from OSA. UARS patients typically have many, many RERAs on their diagnostic PSG and few to no OAs and Hs.