Medical mediator needed

Papit · Post by **Papit** » Sat Oct 12, 2013 2:58 pm

Thanks, robysue, for putting so much thought into your reply. Your inquiries are very pertinent. I'll insert my responses below to easily keep them in context.

robysue wrote:
Papit wrote: anyone else here who’s interested in knowing why a patient’s flow limitation graphs are showing many maximum high spikes every single night while his average AHI is about 1.0 consistently for three months after being switched from the S9 AutoSet to the S9 VPAP Adapt(?). During the patient’s use of the AutoSet for over a year, (my) AHI averaged 17 while flow limitations were consistently very low. What explains these anomalies?

Papit,
I'm not a doc or a tech. So I can't help you wrangle any information out of Resmed.

But I have reviewed your comments in this thread: Re: definition of flow limitation as well as your comments on this thread. You've been asking essentially the same question on both threads:

"Why are my FL so much higher on the VPAP Adapt even though my AHI is so much lower than it was on the AutoSet?

After looking at the data you posted in this response viewtopic.php?f=1&t=91643&st=0&sk=t&sd= ... 45#p845983 very closely, plus what you've said here and elsewhere, I'm beginning to think that the real answer to your question is:

You are comparing apples to oranges
The two machines have different settings and different algorithms and they work in slightly different ways. But the slight differences in the way the two machine work may fully explain why you are getting different results from the two machines.

But in order to really figure out what's going on, there are three pieces of information that I need but cannot find in your posts:

1) What were the pressure settings on the S9 AutoSet when you were using it? [Auto mode: 7 Min, 11 Max] Were you using EPR? If so, at what setting. [Yes. EPR 3, Full time.] And what are your current settings on the S9 VPAP Adapt? [Standard mode "ASV," EPAP: 7.0, Max PS: 10.0, Min PS: 2.0 cmH2O ]

2) Are you using the S9 VPAP Adapt in full Auto mode (where EPAP can change) or are you using it in plain Adapt mode (where EPAP is fixed)? [Plain Adapt "ASV" mode. I tried the "ASV Auto mode for a few days and saw little difference.]

3) On the S9 AutoSet you've stated your AHI averaged 17. What was the break down of the events scored by the S9 AutoSet? Mostly centrals? Mostly OAs? Mostly Hs? [Centrals consistently exceeded Obstructives by a ratio of 3:1 and often higher than that.] (In other words, were you switched to the VPAP Adapt because of CompSA or CSA? [Yes.] Or was there another justification for moving you from the AutoSet to the VPAP Adapt?) [High Centrals compared to Obstructives.]
These three pieces of information are relevant to figuring out why the VPAP Adapt is scoring many more FLs and many less AHI events than the S9 AutoSet did because the answers to these questions control how each machine responds to your breathing pattern during the night; and that response controls how your body reacts to the algorithm, which in turn determines the data you are looking at.

If you were moved to the VPAP Adapt because of clinically significant residual problems with CAs, then the settings on the two machines and the differences between the AutoSet's Auto algorithm and the VPAP Adapt's Auto and Adapt algorithms may be the ultimate explanation for why you are seeing more FL on the VPAP Adapt and less AHI events on the VPAP Adapt.

On the AutoSet, in Auto mode the min pressure setting, the max pressure setting and the EPR setting control the range of possible pressures for each exhalation and each inhalation. As I understand it, on the VPAP Adapt, in Auto mode the min EPAP setting, the max EPAP, the min PS setting and the max PS setting control the range of possible pressures for each exhalation and each inhalation. (The "max IPAP" is equal to Max EPAP + Max PS.) If the VPAP Adapt is set to fixed EPAP mode, then the EPAP setting, the min PS, and the max PS control the range of possible pressures for each exhalation and inhalation. (The "max IPAP" is equal to EPAP + Max PS.)

And even if the settings on your VPAP Adapt seem to be direct translations of the settings on the AutoSet, the differences between the AutoSet's Auto algorithm and both the VPAP Adapt's fixed EPAP Adapt algorithm and the VPAP Adapt's variable EPAP Adapt algorithm can lead to very different (effective) ranges of possible pressures for each inhalation and each exhalation. And this could very well lead to a different physical reaction to PAP pressure in your upper airway. And that's why I think you may be comparing apples to oranges when you try to compare the data from the two different machines: Saying "the AutoSet gave me a higher AHI than the VPAP Adjust" is saying the apple is tarter than the orange and saying "the AutoSet gave me a lower FL than the VPAP Adjust" is saying the the apple less juicy than the orange. [I hope that's not the case. An AHI reading or graph should be accurate and not the same on two machines that utilize two different design algorithms. Ditto flow limitations. Is my body really having more difficulty with obstructive breathing on the Adapt as compared to the AutoSet? That's not what the AHI figures say. Or is the Adapt producing false data or the ResScan software not correctly designed to graph flow limitation data?] Maybe so because, again, my body is not having more difficulty, or at least more discomfort, using the Adapt as compared to the AutoSet.
A long and detailed EXAMPLE
What follows is an analysis of how seemingly similar settings on the AutoSet and the VPAP Adapt can lead to different overall pressure levels when the machines are actually used.

Let's suppose your AutoSet settings were something like these totally made up numbers:
min pressure = 7 cm
max pressure = 15 cm
EPR = 3 cm
On any given exhalation, the pressure would be between 4 and 12 cm. On any given inhalation, the pressure would be between 7 and 15 cm. But on EVERY breath, the difference in pressure would be 3 cm. And any time the machine detected a flow limitation, snoring, or a group of two or more closely grouped Hs and OAs, the machine would raise BOTH the "EPAP" and the "IPAP" by exactly the same amount so that "IPAP - EPAP" remains at 3 cm. The AutoSet does not increase EITHER the "EPAP" or the "IPAP" when it scores CAs---even nasty clusters of CAs. And if the machine is reporting a median pressure setting of 12 cm, that would mean that for at least 50% of the night EPAP >= 9 cm and IPAP >= 12 cm.

Now let's suppose are using your VPAP Adapt in auto-EPAP adjusting mode. And let's assume your VPAP Adapt's basic settings are start out (superfically) looking as close to the AutoSet's as possible:
min EPAP = 4 cm
max EPAP = 10 cm
min PS = 3 cm
max PS = 5 cm
(note this gives us a comparable max IPAP = 15 to the max pressure of the AutoSet's setting).
On any given inhalation, the pressure would be between 7 and 15 cm. But on any given exhalation, the pressure would be between 4 and 10 cm. So there's LESS room for EPAP to increase if the max IPAP is set to the same setting as it was on the AutoSet. And that means that over the course of the night, the average and median values of EPAP pressure are likely to be lower than they were on the AutoSet. And that means there's a better chance that flow limitations can get through since the VPAP Adapt uses increased EPAP pressure to address flow limitations. [But note that flow limitations are reading far higher on the ADAPT and far lower on the AutoSet.]
Of course, we could just allow the max IPAP to go up to 17 and set the VPAP Adapt to something like:
min EPAP = 4 cm
max EPAP = 12 cm
min PS = 3 cm
max PS = 5 cm
(note this gives us a comparable EPAP range to the AutoSet's EPAP range if EPR = 3).
With these settings, on any given inhalation, the pressure would be between 7 and 17 cm. On any given exhalation, the exhale pressure would be between 4 and 12 cm. BUT the difference between the IPAP and EPAP pressures now is allowed to range anywhere from 3 cm to 8 cm. In other words, it is possible that for some periods during the night that the IPAP may be much, much higher than the EPAP. And so the time spent at or near max IPAP may well be significantly greater than the time spent at or near max EPAP. In other words, it's possible that the median IPAP pressure could be 12 cm and the median EPAP pressure could be 7 cm. Now recall that with the AutoSet, if the median IPAP = 12, that meant the median EPAP = 9. And it could be that the difference in median (and 95%) EPAP pressures are allowing more FL to get through.

To make what I'm saying a bit clearer: The Adapt's auto-EPAP algorithm increases the EPAP for flow limitations, snoring, and groups of two or more closely grouped Hs and OAs. But (and this is an important but) the Adapt algorithm also sets a target minute ventilation value based on the patient's (normal) breathing patterns, and whenever the target minute ventilation falls below 90% of the target value, the IPAP is increased, but EPAP remains fixed. This is how the VPAP Adapt treats central apneas.

Now recall that I'm assuming that you were put on the VPAP Adapt because of some kind of problem with central apneas and I'm also assuming that when you were using the AutoSet, much of that average AHI = 17 was made up of central apneas. [True.] If those are correct assumptions, the fact that VPAP Adapt is successfully treating your central apneas may mean that you are spending more time with the EPAP at or near it's minimum setting while the IPAP is ranging much higher in an effort to keep the minute ventilation volume at the target level. And because EPAP is not running as high as it did (on average) on the AutoSet, you see more flow limitations on the VPAP Adapt.

[I'll leave it to others here to comment on that while I mull on it. I sure don't feel any breathing discomfort that I would expect from so many maximum high spikes on the flow limitation graph. Thus I tend to wonder whether they are false artifacts attributable to a lack of design adjustment in the ResScan graph software when ResMed designed the S9 VPAP Adapt. When you make a significant hardware change to produce a new hardware model (the Adapt), the associated performance monitoring software typically requires associated design changes that may not have been made. Thank you for pondering this in such detail. ]

OKCSleepDoc · Post by **OKCSleepDoc** » Sat Oct 12, 2013 6:05 pm

I'll post the same reply as I did in your PM:

So a few things seem strange. I am not currently aware of a "common adjustment" that should be made in this scenario but I would imagine they may recommend increasing the pressure support. AHI and Flow Limitation are relatively independent of one another. Apnea/Hypopnea require a certain reduction in airflow to be tagged as an event, while Flow Limitation is graded based upon the shape of the flow curve. Thus you could have have very high flow limitation, while having a very low AHI, and vice versa, the AHI could be off the chart, but its possible that when not having events if your flow was more regular that it wouldn't have tagged it as flow limitation. Also I suppose if your AHI was high, flow limitation low, and you switched from AutoCPAP to Adapt, that likely the AHI was high due to central apneas (don't know your history here).

In either case, I have my usual Resmed Rep, but I also have a number to the guy who is one of their clinical specialists. I'd be happy to call him and see what his thoughts are and post back to the group. However, I am really busy with some personal things until Thursday of this week. If you don't mind (as I have a tendency to forget), send me a reminder PM on Thursday, and I'll try to give my Resmed contacts a call and see if I can get an answer for you.

OKCSleepDoc · Post by **OKCSleepDoc** » Sat Oct 12, 2013 6:12 pm

How come no one moderates these Trolls? Is there anyone that could do this and ban them from the site?

DoriC · Post by **DoriC** » Sat Oct 12, 2013 6:22 pm

robysue · Post by **robysue** » Sat Oct 12, 2013 6:59 pm

Papit,

I'm rearranging the organization to focus on things from most to least important in my humble opinion.

Your comments are in RED:

Papit wrote:
robysue wrote:2) Are you using the S9 VPAP Adapt in full Auto mode (where EPAP can change) or are you using it in plain Adapt mode (where EPAP is fixed)? [Plain Adapt "ASV" mode. I tried the "ASV Auto mode for a few days and saw little difference.]

3) On the S9 AutoSet you've stated your AHI averaged 17. What was the break down of the events scored by the S9 AutoSet? Mostly centrals? Mostly OAs? Mostly Hs? [Centrals consistently exceeded Obstructives by a ratio of 3:1 and often higher than that.] (In other words, were you switched to the VPAP Adapt because of CompSA or CSA? [Yes.] Or was there another justification for moving you from the AutoSet to the VPAP Adapt?) [High Centrals compared to Obstructives.]

This all by itself explains why the AHI is so much lower on the VPAP Adapt: The Adapt is sucessfully treating your central apneas. The Adapt is specifically designed to treat central apneas and the Autoset is NOT designed to treat central apneas. The whole purpose of switching you to a VPAP Adapt was to treat the central apneas that your Autoset could not treat. Since the Adapt is successfully treating the CAs, the total AHI has dropped because you are no longer having lots and lots of central apneas each and every night. End of the "mystery" of why the AHI is so much lower on the VPAP Adapt than it was on the Autoset.

You also write in RED:

Papit wrote:
robysue wrote:1) What were the pressure settings on the S9 AutoSet when you were using it? [Auto mode: 7 Min, 11 Max] Were you using EPR? If so, at what setting. [Yes. EPR 3, Full time.] And what are your current settings on the S9 VPAP Adapt? [Standard mode "ASV," EPAP: 7.0, Max PS: 10.0, Min PS: 2.0 cmH2O ]

I think these pressure settings may explain why the flow limitations are higher on the VPAP Adapt.

On the S9 AutoSet with the EPR set to 3 and your pressures set as you described them, your EPAP on the AutoSet was allowed to vary from 4 to 8 cm and your IPAP was allowed to range from 7 to 11. On every breath your IPAP was exactly 3 cm higher than your EPAP. Out of curiosity, what were your median and 95% pressure settings from either SleepyHead or ResScan?

On the S9 VPAP Adapt, your EPAP is fixed at 7cm. It will NEVER go down to 4 or up to 8. This may help explain a further reduction in your OAI when you switched from the AutoSet to the VPAP Adapt. Your IPAP will range from 9 to 17 cm, but the only time the IPAP will go up from 9 cm is when your breathing pattern indicates that you are in danger of falling into a CO2 overshoot/undershoot cycle that triggers the central apneas. So whenever you are breathing relatively normally, your IPAP is likely going to be around 9 cm. So you are now more or less using a machine that keeps your pressure at around 9/7 whenever you not having problems suggesting that the CO2 overshoot/undershoot cycle is starting.

Now recall that the S9 will (aggressively) increase the pressure setting in the presence of flow limitations, and your current settings on the VPAP Adapt will NOT increase either the EPAP or the IPAP in the presence of flow limitations because you are using the VPAP Adapt in fixed EPAP mode.

My best guess is that the AutoSet was raising your (IPAP) pressure up to 10-11 to treat the flow limitations when they were very small and that smoothed out the flow limitation graph. But the VPAP Adapt keeps the IPAP down at 9 cm in the presence of flow limitations because you are running in fixed EPAP mode AND the Adapt algorithm adjusts IPAP in response only in response to your minute ventilation dropping below the (running) target minute ventilation number. And a flow limitation does not necessarily affect the minute ventilation numbers since a flow limitation is scored based on the shape of the inspiratory part of the wave flow. Hence a run-of-the-mill flow limitation will NOT necessarily cause the Adapt algorithm to increase the IPAP, and so the flow limitation is not "resolved" through additional pressure (both IPAP and EPAP) when it is still very small.

In conclusion, my best guess is that with the VPAP Adapt's settings, the VPAP Adapt is controlling the obstructive events, including the flow limitations, about as well as a S9 ELITE would with the pressure set to 9cm and the EPR set to 2. And that an S9 ELITE would control the OAs and Hs quite well with these settings, but that the pressure is not quite high enough to iron out all of the scored flow limitations. However, the VPAP Adapt is also doing a much, much better job at controlling your central apneas because that's what it is designed to do. And since the centrals may be pressure induced, there may be good reasons for tolerating the increase in the number of flow limitations scored by the machine because the pressure needed to control them may aggravate the central apneas.

I would suggest that you talk to your sleep doc and ask him to explain how your prescribed settings on the VPAP Adapt are designed to prevent both the OAs and Hs and the CAs and ask him about whether the flow limitations currently being scored by your VPAP Adapt are clinically significant rather than continuing to bug him about the "anomalies" in the data when you compare the data from two very differently designed machines with different settings.

robysue · Post by **robysue** » Sat Oct 12, 2013 7:19 pm

Papit wrote:
robysue wrote: And even if the settings on your VPAP Adapt seem to be direct translations of the settings on the AutoSet, the differences between the AutoSet's Auto algorithm and both the VPAP Adapt's fixed EPAP Adapt algorithm can lead to very different (effective) ranges of possible pressures for each inhalation and each exhalation. And this could very well lead to a different physical reaction to PAP pressure in your upper airway. And that's why I think you may be comparing apples to oranges when you try to compare the data from the two different machines: Saying "the AutoSet gave me a higher AHI than the VPAP Adjust" is saying the apple is tarter than the orange and saying "the AutoSet gave me a lower FL than the VPAP Adjust" is saying the the apple less juicy than the orange. [I hope that's not the case. An AHI reading or graph should be accurate and not the same on two machines that utilize two different design algorithms. Ditto flow limitations. Is my body really having more difficulty with obstructive breathing on the Adapt as compared to the AutoSet? I don't physically feel such a difference in breathing comfort? Or is the Adapt producing false data or the ResScan software not correctly designed to graph flow limitation data?]

As I said in my last post: I think that the current settings on the VPAP Adapt and the differences in how the VPAP Adapt works in standard (fixed EPAP) mode are enough to explain the differences. The two machines react differently to what's going on in your breathing pattern:

The AutoSet raises the EPAP and IPAP together when it detects even a minor flow limitation; but the VPAP Adapt does NOT raise either the EPAP or the IPAP when it detects a flow limitation because its "fixed EPAP algorithm" is NOT designed to respond to obstructive events by raising pressures. Hence the two machines treat flow limitations in a very different fashion.

The Autoset is totally incapable of treating the central apneas by preventing the CO2 overshoot/undershoot cycle, but the VPAP Adapt treats centrals by using a (drastic) increase in IPAP to fix any potential CO2 overshoot/undershoot cycle before it starts triggering central apneas.

So yes, because the VPAP Adapt does not respond to flow limitations by increasing pressure, your body may very well be having more FL when using the VPAP Adapt. But the real questions are:

1) Are those flow limitations----even as severe as they appear to your eyes---clinically significant or not?

2) Would "treating" those flow limitations by increasing your EPAP and min PS settings inadvertently lead to an increase in the number of CAs?

The CAs are KNOWN to be clinically significant for you under ordinary APAP and they may be pressure induced. If treating the possibly clinically insignificant flow limitations leads to an clinically significant increase in CAs, then it ain't worth treating the flow limitations.

Papit · Post by **Papit** » Sat Oct 12, 2013 10:10 pm

OKCSleepDoc wrote:I'll post the same reply as I did in your PM:

So a few things seem strange. I am not currently aware of a "common adjustment" that should be made in this scenario but I would imagine they may recommend increasing the pressure support. AHI and Flow Limitation are relatively independent of one another. Apnea/Hypopnea require a certain reduction in airflow to be tagged as an event, while Flow Limitation is graded based upon the shape of the flow curve. Thus you could have have very high flow limitation, while having a very low AHI, and vice versa, the AHI could be off the chart, but its possible that when not having events if your flow was more regular that it wouldn't have tagged it as flow limitation. Also I suppose if your AHI was high, flow limitation low, and you switched from AutoCPAP to Adapt, that likely the AHI was high due to central apneas (don't know your history here).

In either case, I have my usual Resmed Rep, but I also have a number to the guy who is one of their clinical specialists. I'd be happy to call him and see what his thoughts are and post back to the group. However, I am really busy with some personal things until Thursday of this week. If you don't mind (as I have a tendency to forget), send me a reminder PM on Thursday, and I'll try to give my Resmed contacts a call and see if I can get an answer for you.

____________________

Thanks, OKC. I'll send you a note on Thursday.

Also, re. my history, here's some I sent robysue below that may be useful: 1) What were the pressure settings on the S9 AutoSet when you were using it? [Auto mode: 7 Min, 11 Max] Were you using EPR? If so, at what setting. [Yes. EPR 3, Full time.] And what are your current settings on the S9 VPAP Adapt? [Standard mode "ASV," EPAP: 7.0, Max PS: 10.0, Min PS: 2.0 cmH2O ]
2) Are you using the S9 VPAP Adapt in full Auto mode (where EPAP can change) or are you using it in plain Adapt mode (where EPAP is fixed)? [Plain Adapt "ASV" mode. I tried the "ASV Auto mode for a few days and saw little difference.] 3) On the S9 AutoSet you've stated your AHI averaged 17. What was the break down of the events scored by the S9 AutoSet? Mostly centrals? Mostly OAs? Mostly Hs? [Centrals consistently exceeded Obstructives by a ratio of 3:1 and often higher than that. Hypopneas were modest.] (In other words, were you switched to the VPAP Adapt because of CompSA or CSA? [Yes.] Or was there another justification for moving you from the AutoSet to the VPAP Adapt?) [High Centrals compared to Obstructives.]These three pieces of information are relevant to figuring out why the VPAP Adapt is scoring many more FLs and many less AHI events than the S9 AutoSet did because the answers to these questions control how each machine responds to your breathing pattern during the night; and that response controls how your body reacts to the algorithm, which in turn determines the data you are looking at.

Fyi: Further, it could well be that the ResScan software has not been updated to distinguish, for purposes of specifically graphing flow limitations, whether the FL data source is from the newest Adapt model or the much earlier AutoSet. Btw, the previous Adapt model did not even enable ResScan to display the Flow Limitation graph.

OKCSleepDoc · Post by **OKCSleepDoc** » Sat Oct 12, 2013 10:14 pm

if you can also post a picture of your ResScan detailed report data from both that may help when I call.

49er · Post by **49er** » Sun Oct 13, 2013 2:35 am

OKCSleepDoc wrote:if you can also post a picture of your ResScan detailed report data from both that may help when I call.

OKCSleepDoc,

I am in awe of how willing you are to go out of your way to help an internet poster you don't even know. And I am sensing you are a heck of a sleep doctor and the type of physician that so many of us wish we had.

49er

jnk · Post by **jnk** » Sun Oct 13, 2013 8:10 am

OKCSleepDoc wrote:How come no one moderates these Trolls? Is there anyone that could do this and ban them from the site?

Here is a statement from the site owners (with which I have no connection, other than as an occasional customer):

johnnygoodman on Thu Jun 07, 2007 wrote:My approach to moderating cpaptalk is well known. Here's the basic rational:

Beware the person who wishes to legislate the morality and the behavior of his neighbor. Respect the person who accepts as responsibility, duty and sacred privilege the task of successfully moderating his own behavior. People who can do this are rare beacons of light. It is easy to point the finger "elsewhere" and imagine a utopia will result. It is hard to do the work and take responsibility to make your first utopia internal. Paraphrasing Ghandi - be the change you wish to see in the world.

There are no rules, no distant moderator, no respected member of the community that can legislate or moderate away our own foul dispositions. If this were not true, one of the many forms of government our forefathers have tried would have worked. For another example of the rhetoric used by people who advocate such a position, read literature from those favoring prohibition before its enactment. These people believed sincerely in their cause, they had good intentions and were good people but their actions were doomed to failure from the start.

How does all of that lofty philosophy play out in real life? In the most basic terms,
I'm trading value for value. I provide the domain, the hosting, the software and the moderation of CPAPtalk in accordance with my set of beliefs regarding human nature and business. You may use it free of charge, you may find a better board or you may start your own.

There will be no additional moderators on CPAPtalk. The core values of this board will continue to govern it. Love your neighbor and be a neighbor others can love.

Johnny

viewtopic.php?f=1&t=20895&p=179739#p179739

Banning and/or moderating does, indeed, occasionally occur, when necessary:

viewtopic.php?f=1&t=56555&p=530710#p530710

viewtopic.php?f=1&t=52681&p=486719#p486719

viewtopic.php?f=1&t=33457&p=284387#p284387

viewtopic.php?f=1&t=50275&p=462030#p462030

By the way, OKCSleepDoc, please feel free to correct anything I've said in this thread that you think could be misleading to Papit or to any reader who may come across this thread in the future. We all do that for one another on here all the time.

Personally, as a fellow poster but one with no medical training whatsoever, I would like to say thanks for participating in this thread and for your kind offer to Papit.

DoriC · Post by **DoriC** » Sun Oct 13, 2013 10:46 am

It is amazing that a practicing sleep dr would give so freely of his time to help us. Since some of my problems are unique to my unusual situation I've taken the liberty of sending one or two PMs to OKC for his opinion. I would never impose otherwise and would only post a question online. He has replied promptly and his explanations are simple and to the point. He's one of the good guys!

49er · Post by **49er** » Sun Oct 13, 2013 10:50 am

DoriC wrote:It is amazing that a practicing sleep dr would give so freely of his time to help us. Since some of my problems are unique to my unusual situation I've taken the liberty of sending one or two PMs to OKC for his opinion. I would never impose otherwise and would only post a question online. He has replied promptly and his explanations are simple and to the point. He's one of the good guys!

I have had similar experiences with this physician DoriC.

49er

Papit · Post by **Papit** » Tue Oct 15, 2013 1:31 am

OKCSleepDoc wrote:if you can also post a picture of your ResScan detailed report data from both that may help when I call.

Sure. Please set your monitor for full screen viewing. The images at the bottom of the page include my Settings, Statistics, Summary Graphs (2 months) and Detailed Graphs on a sample day using both the AutoSet and the current (2nd generation) VPAP Adapt. Notice how ragged my flow is on the Adapt, but I see no correlation with the high FL spiking. For some reason, the AutoSet never would give me a Flow graph, but showed very low flow limitations. I wonder if ResMed might like to borrow either or both machines to look them over. Note that my use of the Adapt's Auto mode for a week in early September seems to have had no noticeable effect.

OKCSleepDoc wrote:[Earlier reference] I'll post the same reply as I did in your PM:
So a few things seem strange. I am not currently aware of a "common adjustment" that should be made in this scenario but I would imagine they may recommend increasing the pressure support. AHI and Flow Limitation are relatively independent of one another. Apnea/Hypopnea require a certain reduction in airflow to be tagged as an event, while Flow Limitation is graded based upon the shape of the flow curve. Thus you could have very high flow limitation, while having a very low AHI, and vice versa, the AHI could be off the chart, but its possible that when not having events if your flow was more regular that it wouldn't have tagged it as flow limitation. Also I suppose if your AHI was high, flow limitation low, and you switched from AutoCPAP to Adapt, that likely the AHI was high due to central apneas (don't know your history here).

In either case, I have my usual Resmed Rep, but I also have a number to the guy who is one of their clinical specialists. I'd be happy to call him and see what his thoughts are and post back to the group. However, I am really busy with some personal things until Thursday of this week. If you don't mind (as I have a tendency to forget), send me a reminder PM on Thursday, and I'll try to give my Resmed contacts a call and see if I can get an answer for you.

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hueyville · Post by **hueyville** » Tue Oct 15, 2013 7:35 am

I AM 110% IMPRESSED!!! With the above quote from site owner and modedator. I participate on several boards with multiple moderators that at times let their personal feelings interfere with the free exchange of ideas. Nothing worse than seeing one mod delete a post then another reinstate it then even more confusion enters into the original problem post/poster. I also moderate on two sites and both we have a separate unseen forum for the moderators to discuss the site and quite often person(s) that may need to be banned. I have seen moderators go to war which really adds to the confusion. A benevolent monarchy is the best way to go. If one person has the resources, skills and time to do this especially when doing it with a motivation toward the greater good of the community such as the owner of this site apparently does then it should all work out for the good of most. I know I have made a few posts that some mods might have sent me a pm advising a little more discretion in wording my ideas but it has not happened yet. Complaining about tbis place is as selfish as the people.that complain because Sleepyhead does not do what they want. A talented person wrote a wonderful piece of software, gives it away along with all the code so anyone that wants can modify it or improve it, helps those who have difficulty with it when can, updates and adds features and it just plain works.

I lurked here for a couple months before joining and once I did register have been fairly active. The toleration of trolls until proven beyond a shadow of doubt takes much more patience than I am capable of. I would more likely err out of impatience and block some folk needing help but may not necessarily have good social skills, tact, understanding of concepts many of us may consider common sense or ettiquite. Taking time to be patient before banning the trolls is a very "American" Bill of Rights ideal. I would be likely to kick some poor soul out of the group that needed help before figuring out their true personality and helping someone in need. Enough off topic threads are tolerated without them getting out of line. Personally my preference for a BBS like this is no topics on politics, sports, jokes, etc. Hiding behind that is my own propensity to occasionally participate in them. Political discussions as they pertain to health care law is almost required. Also over time a sense of community develops among us folk who may have a lot.of differing ideas outside of our common bond of sleep d. Considering minimum moderation that I see on the surface this place runs pretty well. So kudos to tbe proprietor of this bin oc nutts, myself included. I hope this place continues to operate and thrive as it aids folks like me who are sick and need information outside of the structure of my monthly meeting with sleep doctor or weekly meeting with respiratory tech. Combined with a new doctor, tech, lab, this website and advice from y'all my apnea has seen major improvement. Diagnosed 2.7 years ago with avaerage AHI bouncing between 50 and 90, I saw no improvement of significance for over 2 years. New doc and armed with tons of information from here my average AHI thus far for the month of October is 10.7. Considering docs originally said I would probably never get below 15. I have another trip to lab tonight and two more this year. I am actually confident that we will get my average below 10. My goal is the 5 to 8 range. Original doctor quit me when after 6 months my AHI was still in the 30 to 50 range. New doc and this site has provided miraculous results. Thanx everyone for all tbe advice.

Now to the subject of the O.P. starting this thread was confusing at best and when I read about a patient whose doctor, DME and the manufacturer of the equipment will not communicate with him anymore to point of written notifications alarms start ringing from every direction. I consider myself a bit outspoken but never had a doctor tell me to leave him away. My docs know when I call something is wrong and schedule me right up. So yes, I reread my posts to tbis thread and some are borderline harsh. But when I read about someone freaking out about an AHI of 1 and his doctor wont explain his graphs in detail I assume the O.P. may be demanding too much. I understand the desire to be informed but daggum... The doc is happy and score is 1.

49er · Post by **49er** » Tue Oct 15, 2013 7:54 am

Now to the subject of the O.P. starting this thread was confusing at best and when I read about a patient whose doctor, DME and the manufacturer of the equipment will not communicate with him anymore to point of written notifications alarms start ringing from every direction. I consider myself a bit outspoken but never had a doctor tell me to leave him away. My docs know when I call something is wrong and schedule me right up. So yes, I reread my posts to tbis thread and some are borderline harsh. But when I read about someone freaking out about an AHI of 1 and his doctor wont explain his graphs in detail I assume the O.P. may be demanding too much. I understand the desire to be informed but daggum... The doc is happy and score is 1.

Hi hueyville,

I understand your perspective in light of what you have been through but many people with a 1 AHI and below are floundering big time for mysterious reasons and get blown off by their doctors because their case is too complex which leads to them being fired as patients. So if OKCSleepdoc is willing to help the OP perhaps access the information that he needs, who are we to say he is demanding too much.

49er

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