Can someone please help me

[OKCSleepDoc]

Here's what some of you don't understand. Here's what a lot of doctors DON"T understand. The personal stuff matters

here's what YOU don't understand... whether or not your hubby can get it up really has nothing at all to do with the efficacy of his cpap treatment, which is what we're trying improve here.

Actually, palerider, for the smart ass that you take yourself to be, there are actually multiple studies that link ED to untreated OSA and show that with the treatment of OSA, ED symptoms improve significantly. perhaps you should do your homework before throwing out incorrect statements that are baseless.

The fact that her hubby can get it up or not may entirely have to do with the efficacy of his cpap treatment.

[palerider]

Actually, palerider, for the smart ass that you take yourself to be, there are actually multiple studies that link ED to untreated OSA and show that with the treatment of OSA, ED symptoms improve significantly. perhaps you should do your homework before throwing out incorrect statements that are baseless.

The fact that her hubby can get it up or not may entirely have to do with the efficacy of his cpap treatment.

and, how do *YOU* oh god of sleep medicine, propose to optimize his therapy?

by asking her if hubby can get it up, or by getting the right data to see what appears to be wrong with the treatment, AND FIXING THAT?

[Roman Hokie]

you have it backwards... nasal masks, and even more so pillows, require *MORE* pressure at the machine, to compensate for the smaller holes, and thus more restrictive interface.

this is handled automatically by setting the mask type appropriately.

the same as a smaller hose requires more at machine pressure than a larger one, because it's more restrictive to the flow.

Thanks, palerider. You're right, of course. Larger area hose gives less pressure despite a higher flow-rate. Smaller hose gives more pressure and a lower flow rate (the golf ball through the garden hose analogy applies).

[OKCSleepDoc]

[and, how do *YOU* oh god of sleep medicine, propose to optimize his therapy?

by asking her if hubby can get it up, or by getting the right data to see what appears to be wrong with the treatment, AND FIXING THAT?

Several Ways but before we begin:

1. I have never thought of myself as a GOD, but wow, I never knew you looked up to me like that. Come to me my son, I shall show you the way. From now on you can refer to me as Morpheus, and I will refer to you as cockrider.

2. While I don't think of myself as a GOD, I am fellowship trained, board certified in sleep medicine. I am an international speaker, have published articles, written chapters, and have been trained by the very people who coined the term OSA and AHI. So no matter what, I do love the fact that you will NEVER be more knowledgeable than me in regards to sleep medicine. PERIOD. HAHAHAHAHAHAHAHA.

Now onto more serious matters:

1. Having the download information will help to see if there are any areas with which to optimize his pap therapy. One thing you may want to remember though is that many individuals are not that knowledgeable about technology and furthermore PAP machines. I don't think that she is not trying to share the data, but she may not be as comfortable with understanding all the steps to download and upload her data. Cockrider, While you and I may feel very comfortable in front of a computer, many people are not. A little patience can go a long way.

2. In medicine, it is very important to treat the patient and not a number. You can chase the AHI all day, or you can consider symptomatic improvement as well. If his pap therapy is optimized and perhaps his AHI still hovers around 4 or 6 or whatever thenumber,if he reports benefit in Epworth, daytime function,daytime cognition, ED, etc, then knowing these facts are essential in providing him the best care.

No worries padawan, you will get there some day.

[Pesser]

He is using an APAP? Why isn't the pressure going up after 5:30?

Because APAPs can't/won't respond to centrals with more pressure. It's part of the algorithm for apaps...they only respond to obstructive in nature apnea events....not centrals at all.

I few months ago someone posted an advertise by Resmed. It showed a person not breathing and compared the response time between a Resmed and Respironics. So that means that the artificial person (dummy) was having an obstructive and not a central. How did the techs pull this one off! Did the dummy have a brain and was not having the right brain wave..... how is the unit making the distinction between the two apneas? It has to be by sensors. The lack of response and the pressure response must be telling the unit the difference. The next breath must be at a higher pressure?

If this person is having centrals then they need a unit that treats centrals. Would you agree that a unit, even an apap can cure centrals over enough time and at the right pressure?

[archangle]

(i.e. if he started with a nasal mask or pillows, that may not be enough pressure for the full face).

I realize I'm grasping at straws here...

you have it backwards... nasal masks, and even more so pillows, require *MORE* pressure at the machine, to compensate for the smaller holes, and thus more restrictive interface.

this is handled automatically by setting the mask type appropriately.

the same as a smaller hose requires more at machine pressure than a larger one, because it's more restrictive to the flow.

This issue is more complicated than it sounds at first.

---

A full face mask pushes back on the jaw. If this moves the jaw backwards, it can make the patient's apnea worse. It's sort of like an oral apnea appliance, but it's working against the patient. It's hard to evaluate how much this matters, and obviously, it will vary between patients. Some of the pros at binary sleep think it's a big deal, and a number of people report needing more pressure with FFM.

---

As for the mask resistance leading to lower pressure, that's even more complicated. There's no net airflow through the mask into the patient. Air goes in on inhale and then goes back out, but the volumes balance. (other than mouth leaks.) The average pressure over the breathing cycle would be the same. More resistance would slightly lower the pressure during inhale and increase it during exhale.

It's a bit different from the effect of a narrow CPAP hose because there is a net airflow through the hose due to the exhaust port. Past the exhaust port through the pillows to the patient's lungs, there is no net airflow.

What that means in terms of apnea therapy is a complex issue. When you're actually in apnea, airflow is zero, so the mask resistance does not affect the pressure in the airway. The pressure would only drop during the inhale cycle, and even then only in proportion to the airflow. The effect only becomes significant during the part of the inhale cycle when you're already inhaling deeply.

[archangle]

If this person is having centrals then they need a unit that treats centrals. Would you agree that a unit, even an apap can cure centrals over enough time and at the right pressure?

In concept, central apnea needs T or ST mode bilevel or ASV. Constant pressure CPAP or APAP will not help or may make it worse due to pressure induced centrals. However, the human respiratory system, including the brain and nervous system, is complex. Sometimes, a CPAP or "normal" bilevel will make an improvement in centrals.

I few months ago someone posted an advertise by Resmed. It showed a person not breathing and compared the response time between a Resmed and Respironics. So that means that the artificial person (dummy) was having an obstructive and not a central. How did the techs pull this one off! Did the dummy have a brain and was not having the right brain wave..... how is the unit making the distinction between the two apneas? It has to be by sensors. The lack of response and the pressure response must be telling the unit the difference. The next breath must be at a higher pressure?

I think I know the ad you mention. I consider it to be mostly marketing BS. The "dummy" was a device that simulated breathing for CPAP testing. Depending on how it's designed, the simulated apneas would look like obstructive or central apnea to the CPAP machine. It would depend on what happens to the airflow as the CPAP rapidly varies the pressure up and down.

[palerider]

As for the mask resistance leading to lower pressure, that's even more complicated. There's no net airflow through the mask into the patient. Air goes in on inhale and then goes back out, but the volumes balance. (other than mouth leaks.) The average pressure over the breathing cycle would be the same. More resistance would slightly lower the pressure during inhale and increase it during exhale.

It's a bit different from the effect of a narrow CPAP hose because there is a net airflow through the hose due to the exhaust port. Past the exhaust port through the pillows to the patient's lungs, there is no net airflow.

you're not thinking it through.

cpap pressure is a dynamic, active thing, affected by many factors, whether there's a humidifier (set automatically) whether there's an AB filter, size and length of hose, type of mask. all of these things resist airflow and cause pressure drops.

if the machine were to simply say "well, I've got 15cm at my pressure sensor, I'm good!" then you'd be having substandard treatment, because when you went to inhale, you'd NOT get 15cm of pressure to hold your airway open.

as you can see in the following diagram, the pressure generated at the machine isn't what ends up being experienced at the mask.

where intended pressure delivery is what's desired that the patient experience, and actual pressure is what's generated in the blower unit.

it has nothing to do with net volume, it has to do with fluid dynamics, with FLOW, flow through your airway and controlling the pressure dynamically so that you get the appropriate pressure in your face.

of course, the only way you could see that would be with high rate graphing manometers connected at the machine outlet, (before the humidifer) and inside the mask. my dual port manometer doesn't record data, and doesn't update fast enough to be able to make a chart, but it's easy to see the pressure differential on the two ends of the patient circuit.

[palerider]

No worries padawan, you will get there some day.

you're fired... go speak internationally somewhere else. we come here to get away from your sort.

have a nice day.

[chunkyfrog]

Well said, oh halo-wearing sage.

[palerider]

few months ago someone posted an advertise by Resmed. It showed a person not breathing and compared the response time between a Resmed and Respironics. So that means that the artificial person (dummy) was having an obstructive and not a central. How did the techs pull this one off! Did the dummy have a brain and was not having the right brain wave..... how is the unit making the distinction between the two apneas? It has to be by sensors. The lack of response and the pressure response must be telling the unit the difference. The next breath must be at a higher pressure?

If this person is having centrals then they need a unit that treats centrals. Would you agree that a unit, even an apap can cure centrals over enough time and at the right pressure?

I probably posted that. and unlike arch and his quick dismissal as 'marketing bs' (I don't believe it was a resmed marketing video, it was a comparison done by a DME, though I could be wrong about that.) , I'd say it's very simple for a dummy to simulate centrals and obstructives.

what's the essence of a throat/lung? a tube with an elastic bag on the end of it. raise the pressure presented to the tube, and the bag expands, lower it, and the bag contracts due to elastic forces. (think a large balloon). put that balloon in a sealed container with a rubber sheet on the floor, and you've got the essence of a ribcage and diaphragm science fair style:

and even a diy video.
https://www.youtube.com/watch?v=mhiPrjcC7Kk
you could use that with a cpap to simulate breathing, and apneas.

to simulate a central, you simply quit pulling on the 'diaphragm' and let things sit. machines then do their routine to see whether the airway is open by pulsing pressure, and watching the response, if there's flow into the lungs and relatively little pressure spikes when pressure is increased, it signifies that the airway is open and the pressure is being absorbed by the elasticity of the lungs.

to simulate an obstructive, you put a valve up at the top, or pinch off the tube coming out of the model, where the cpap hose would attach. then when the machine pulses air, there's relatively LITTLE flow, and much sharper pressure spikes... and the machine scores an obstructive.

make sense?

normal machines don't respond breath by breath, but depending on brand, pressure will get adjusted sooner (resmed) or later (respironics) to hopefully head off future obstructive apneas.

https://www.youtube.com/watch?v=lzCCgNLya_g
https://www.youtube.com/watch?v=Awpp5lvi3I0

[stardust123]

Yes Pugsy I am going to try and ask him if he will push button on machine when he is awake. He did not do that here.

He had real rough night last night. He said he was awake off and on from about 3 am. His hip hurts and woke up a lot. I am trying to take a look at these events. Most look like falling asleep or waking. He's been stressed about his work. The problem with Kaiser is there are 2 Sleep doctors. We already saw one. The 2 GP Doctors were clueless, in fact, they both MISSED THE ENTIRE PROBLEM. So yes I can switch regular doctors as many times as I like but it won't matter, because I need the sleep doctor and there are only two. I am going to post a picture.

I am not going to dignify some of these comments with an answer. It's the honest to god truth that sleep disorders cause ED. I am sorry that people are uncomfortable facing that reality. Sleep disorders also cause hearing loss BTW, but I don't suspect anyone will give me grief about that. Considering most people don't have an emotional baggage related to hearing loss. Here you go. I appreciate ALL of you, because you are kind to help me. http://imgur.com/a/nIQHj HEre is good shot of pressure. http://imgur.com/n2G0rmE

When I was listening to him sleep. I did not hear the holding breath thing that I had been hearing. I only heard that once this morning.

[Julie]

Oh geez, you're still missing the point! OSA can cause ED. We know! We've known that for years. But we're trying to help you with the TECH stuff now. That's the issue at hand, not ED! Go on Dr. Phil if you want to talk about that and all the other personal tribulations you have - we've all been there, done those a thousand times and are not arguing that they accompany OSA, but talking about it won't help what you need right NOW! Get over yourself and try and help your husband instead of berating us for trying to stick to the point YOU asked about in the first place.

[stardust123]

Julie, the reason I brought it up, is so you can tell if the problem is being fixed.

Let's us make this really simple:
1. The problem is fixed when the symptoms go away or get better!

2. The numbers are just a manifestation of the symptoms.

3. To better understand if the treatment is working, symptoms must be noted.



Right now, I am trying to figure out if these are Centrals or just clear airway events. If his symptoms are BETTER, then it's probably a clear air falling asleep/wake thing and NOT a central events. And that why I put down what symptoms he is having.

[palerider]

It's the honest to god truth that sleep disorders cause ED. I am sorry that people are uncomfortable facing that reality.

the point that you refuse to understand is that it doesn't MATTER if sleep disorders cause ED. that's something that might be useful in a screening quiz to see if someone should be tested for sleep apnea, given that your poor husband already has a machine, it would appear that we're well past that point now.

sdb can cause many things, here's a short list of things worse than impotency:
High blood pressure
Stroke
Heart failure, irregular heart beats, and heart attacks
Diabetes
Depression
Worsening of ADHD

and of course, many more things.

NOBODY HERE IS DISPUTING THAT.