- Tell me, if this sounds familiar,
you're on CPAP and your AHI numbers are great,
but you're still really tired.
What the bloody hell is going on?
Isn't this therapy supposed to make us feel fantastic.
I think I might have found the answer.
Let me show you.
In today's SleepHQ case study,
I'll expose some hard truths
about CPAP data accuracy
and I'll teach you some fundamental skills
to help you validate those often misleading results.
Let's do it.
(electronic noise)
- This is your last chance
after this there is no turning back.
If you take the blue pill, the story ends.
You wake up in your bed
and believe whatever you want to believe.
You take the red pill, you stay in Wonderland,
and I show you how deep the rabbit hole goes.
Remember, all I'm offering is the truth. Nothing more.
- Firstly, thanks to Joe,
who kindly invited me to his SleepHQ account
and authorized me to share his data
with you today, Joe, to show my appreciation
I'm sending you a REM sleep O2 ring buddy,
(cheering and clapping)
that you can use to monitor your blood oxygen levels
and also your heart rate.
And this ring will shortly be integrated
fully with SleepHQ, which is very exciting.
Now today's video will mainly focus on
the apnea hypopnea index.
Which is how many respiratory events someone is having
per hour, per night.
And on this particular day up here, top left hand corner
you can see he had an AHI of 6.32,
which was up 4.2 from the previous night.
Now at first glance, 6.32 isn't too bad.
Well, it doesn't seem too bad.
As we all know the goal is to try and get that number
under five, if we can,
but 6.32, eh, it's not too bad.
It's still very, very mild.
Okay, room for improvement.
Most of you would assume that all this detailed data
all these numbers,
provided by the manufacturers on the CPAP machines
would be fairly accurate.
I mean, it's a medical device after all,
especially that apnea hypopnea index.
Because that's the number we use to validate the therapy.
Efficacy.
How well is your CPAP therapy controlling your apnea?
That's the number we all use.
Well, what I'm about to show you might shock you a bit.
Now, let's scroll down the page
and take a look at Joe's airflow.
Let's see how he's breathing.
And this is what's so special about sleep HQ.
We get this full high definition,
full detailed CPAP therapy data.
And you just don't get this information
on your myAir app or your DreamMap app.
We can see each individual breath that Joe takes
through the night on the flow rate.
Here's the flow rate.
Now it looks like a great big mess.
And that's because we've condensed
thousands and thousands of breaths,
individual breaths into a very short space.
But what we can do is we can zoom in
and it will become much more clear as you can see right now.
I can also hit the Z on my keyboard, which will zoom in.
And here we go.
We've got a great snapshot
of Joe's breathing at this point in time.
So you can see right here down the bottom
we've got the timestamps and they're 30 seconds apart.
And to me, this breathing looks really, really good.
It's nice and regular.
It's nice and consistent.
It's nice and stable.
That's what breathing should be.
Breathing is never gonna be perfect.
We're not trying to get it perfect,
but we just want it to look fairly stable.
All right, you can see him breathing in
and breathing out.
As the line comes up, he's breathing in
and as the line goes down, he's breathing out.
Now what we can do
is we can hit the right arrow
and we can start scrolling through the night.
Now you're about to see something change.
All right.
Now, remember before let's go back a bit.
Let's have a look at his breathing here.
Okay. Let's have a look here.
Nice and stable.
Nice and consistent.
Nice and regular.
Let's move forward a few minutes.
So we're going forward here.
Can you see how now it's very irregular.
You've got these periods here
where he's taking these great big breaths.
And then you've got all these little shallow breaths.
Look how small some of these breaths are here, right?
He's having irregular breathing now.
These are what we call hypopneas.
You don't really need to know all the classifications
and all the terminology.
What you need to be able to do is just visualize
and see the difference between regular breathing
which was what I showed you before the baseline.
And when breathing turns shit,
like it is now.
Right in the middle, you can see here
we have this vertical gray line
that has a H on it.
And that H stands for Hypopnea.
Now this line is a
respiratory flag
provided by the CPAP machine.
So the CPAP machine algorithm is monitoring the breathing.
And it's decided that right there is a hypopnea.
But do you notice anything?
If we zoom out, where's all the rest of the flags?
Right? We've got one over here,
but where's the one here.
Where's the one here.
There's a whole bunch of flags missing.
Let's scroll forward and you'll see some more.
Once again, there should be a flag right here.
You can see the breathing has got really narrow
and then he's gone (deep in/out breath sounds).
Any sleep tech, any chimpanzee,
with a set of eyes can see clearly
that the airway has become very narrow here
for longer than 10 seconds.
And it should be marked with a flag and it's not.
And this is the point I'm trying to show you in this video.
So let's quickly talk some numbers.
Now on this particular night,
the ResMed CPAP flagged 51 respiratory events,
which gives us an AHI of 6.32, doesn't sound too bad.
Hey, no cause for concern.
Well, I invited five qualified sleep techs,
including myself, 14 years experience,
to review the same airflow, to review Joe's breathing
and do a manual count,
count up all the flags as they saw it.
And you know what the lowest count was?
It was mine,
115,
which gives an AHI of 14.3.
That's a massive difference.
Let's zoom out and have a look at Joe's therapy trend
over a larger timeframe.
Let's go a whole month.
Now this top chart here is the AHI trend
and we just looked at Monday the 16th of May right here,
AHI is 6.32.
Now there's another day that grabs my attention.
It's this day over here, the 5th of May
and his AHI was nine.
Now the day before that, the 4th of May, it was 1.91.
So that's a big jump on that particular day.
Let's scroll down a little bit and see
if Joe might have changed his therapy pressure levels.
And he did.
Now, this was the 4th of May.
And you can see here, he's got a max pressure of 10.8
and then one day after he drops it to 10.4.
And I really want to emphasize that point
sometimes really small changes
to your therapy pressure levels
can result in big fluctuations in your apnea control.
So you really need to monitor it, especially
if you're gonna be dropping those pressure levels.
All right. So let's go to the fifth.
All right. So we'll go back to the dashboard,
the daily view and we'll go to the fifth.
Here we are on the fifth,
apnea hypopnea index of nine up 7.09 on the previous day.
Now, let's go down and have a look
again at the breathing.
All right. So once again,
you can see it very clearly.
So the ResMed machine, it's marked one flag.
You can see there's one flag here
but there needs to be more.
There should be a flag here, here
here, here, here, here, here, here.
It's missing a whole bunch of flags again.
And once again, we've done another count.
So on this particular night,
ResMed flagged 57
events in total
with the AHI of nine
and the sleep techs, the minimum was 110 events
with an apnea hypopnea index
of 17.3.
Some of the sleep techs was scoring 150 flags.
All right. But the lowest, which was me again, was 110.
I'm quite conservative,
especially when I'm dealing with CPAP machines.
Alright, so once again, guys, just a massive difference
almost double and to any other sleep techs
that are watching g'day mates.
I've put a share link to this flow rate data
in the description of the video.
So if you're interested, feel free,
click the link and you too can analyze the flow rate.
Give us a count and put it in the comment section below.
So what on earth is going on?
Why is ResMed, supposedly the market leader,
missing so many apparent flags?
And is this potentially by design, let's find out.
The problem is this,
ResMed and all the other manufacturers,
not just ResMed.
I know I'll pick on ResMed a little bit.
They've set the hypopnea flag thresholds, very high.
So all these hypopneas
here, here, here, here, here, here, here,
that would typically be marked by a sleep tech
or anyone with a pair of eyes,
a chimpanzee for God's sake.
All these events are not getting flagged.
And they're flying under the CPAP radar,
because they're not meeting the strict criteria
set by the manufacturers.
And that right there is the problem.
CPAP machines are just computer code.
They see everything black
and white
ones and zeros.
Where sleep apnea,
It's a, it's a human condition
that has many shades of gray.
And that's why you need human eyes
to spot those problems.
So unless your airflow drops
by a massive 50% for 10 seconds or more
ResMed doesn't feel there's a problem.
They won't flag the events.
It doesn't meet their strict criteria.
How you could be having hundreds
of 40% drops a night, just like Joe,
severely affecting your sleep quality.
And you wouldn't even know it,
although you'd probably feel pretty shit during the day.
And that's what many of you are reporting?
All the industry professionals, the doctors,
the clinicians, the specialists,
the sleep techs we're all using this AHI number,
generated by the CPAP machine
as a guide for treatment efficacy,
as a guide to tell us how well
the therapy is controlling a patient's apnea,
but it's not accurate. It's nowhere near accurate.
The machines are getting it wrong.
And so we are getting it wrong.
And you guys, you are the ones who suffer
because you machine is telling you
that it's controlling your apnea
and it's not.
So what can we do about it?
Well, it's pretty simple, really.
We just need to take a look at how you're breathing.
We need to take look at the flow rate
and I'll show you that now.
Now you've got two options when it comes to this
and they're both free.
You can use my sleephq.com, which is my platform,
the one we're using now,
and that will work for most ResMed machines
and the Dream Station One.
And we're integrating new machines every month.
But if you have a different machine
and you want to check it now.
Then you can also download some open source software.
That's called Oscar.
And I'll put a link to Oscar
in the description of the video,
but I'll show you on my platform now.
The first thing you guys need to do
is see what your normal breathing looks like.
And you can find that at the start of the night
before you go to sleep.
So let's zoom in on Joe's flow rate.
This is how he breathes when he's awake
and it looks fine.
It looks natural.
It's nice and stable. It's nice and regular.
Once you get a mental image
of what your regular breathing looks like,
you can then scan through
the rest of the night and have a look
at periods where it might not look like this.
That's all there is to it.
I'm not expecting you guys to become sleep techs overnight.
And know what a hypopnea is,
obstructive apnea, central apnea, mixed hypopnea,
all these bullshit terminology.
You don't need to know it.
All you need to know is that looks good.
That looks shit.
That's it.
So let's just go to a part now
where Joe's breathing does look shit.
All I'm doing here is just clicking my mouse and dragging
over a section of interest
and I'll do it again.
Now you can clearly see, you don't need to be a sleep tech
to see that this looks completely different
to our baseline breathing and nice regular stable breathing.
Something's changed. The pattern has changed.
Keep an eye out for these patterns.
Right, but we have these little narrow breaths.
(shallow quick breathing sounds)
And then all of a sudden, these great big
(deep breathing sounds)
Where the breathing's basically catching up,
trying to get more oxygen into the blood.
I'll zoom in a little bit more.
Now, when you're scanning through your flow rate,
just using the right arrow and you're going through
and you find these sorts of patterns.
The next thing you do is see if they're flagged
and you can see here, we've got a flag here, a flag here.
It's missed one here, right?
That's not too bad. It's missed one.
But if there was only one here,
one H and then the rest didn't have flags.
Well, that's sort of like a,
you know, a warning signal for you
that perhaps your apnea hypopnea index,
isn't what you think it is.
Right? So we'll go through here a bit more.
All right. So it's flagged here.
That's good.
It's flagged here. It's flagged here.
It's quite accurate here. It's flagged.
It's missed this one.
It's got this one.
So it's, it's missing a lot.
Many CPAP users also use, O2 rings,
like this one here,
to monitor their blood oxygen levels
and heart rate through the night.
And they use this information
to then substantiate the CPAP report.
It stands to reason that
if your blood oxygen levels are good
then your breathing's probably not too far behind.
Old mate Joe did request some insights
and therapy recommendations.
So here's my thoughts.
G'day, Joe, mate.
There's clearly some periods throughout the night
where your CPAP pressure is inadequate.
This is most likely during REM sleep
or potentially when you're on your back.
Now, if you continue with CPAP mode,
I'd increase your pressure up to 13.
Try that for a few nights
and then evaluate the improvements.
Alternatively, you could try auto CPAP
but with a tight range.
I'd set your AutoMin to 11 and you AutoMax to 14.
Once again, try it for a few days
and evaluate the improvements.
Perhaps we can check back in with you in a few weeks time
and check how your SleepHQ data is trending
after the changes.
Thanks for watching everyone. (guitar playing)
The take home message is trust, but verify.
Don't go blindly into the dark,
grab your SleepHQ torch
and shine it right on your breathing.
Until next time sleep well.
And look after your mates. Bye.
(electronic noise)
(beeping and ringing sounds)
- [Neo] I know you're out there.
I can feel you now.
I know that you're afraid.
You're afraid of us.
You're afraid of change.
I don't know the future.
I didn't come here to tell you how this is going to end.
I came here to tell you how it's going to begin.
I'm going to hang up this phone,
and then I'm going to show these people
what you don't want them to see.
I'm going to show them a world without you,
a world without rules and controls,
without borders or boundaries,
a world where anything is possible,
(electronic computer sounds)
Where we go from there is a choice I leave to you.
(tense music)
(rock music)
(electric guitar music)