Bi-Level, S, ST, ASV??

[vsheline]

Having been on the receiving end of a BiLevel sleep lab titration without "Easy-Breathe" or similar and it was hard.  Inhales and exhales were like throwing a switch, The There was no "ramp time, it was either on or off, very much a square wave application.  Have you EVER seen a breath wave form where the change happened instantly?  It is a big deal.

I use an Aircurve 10 ST-A machine.  It does not have the Easy-Breathe option in any of its therapy modes.
I have the Rise Time option adjusted to a large value (750ms) to make the pressure rise at the start of inhalation slow/smooth, but there is no Fall Time option, so the pressure drop at the start of exhalation is abrupt.
Earlier, I had used for years an S9 ASV machine with Easy-Breathe, and I strongly missed Easy-Breathe for a few weeks when I changed to the ResMed ST-A, but now (as long as I use a long Rise Time) I have pretty much gotten used to it and have learned to ignore the abrupt pressure drop at the start of exhale.
Years ago, ApneaBoard member Goodonya struggled and tried very hard to use a Philips Respironics ASV machine without success (was mostly unable to sleep using the machine) but later was successful using a ResMed ASV, because of ResMed’s smooth Easy-Breathe waveform. 

Take care,
— Vaughn

[jtech1]

Thanks for all the feedback!

I spoke to Dr and even thought they have backup rate OFF on current script, they want to use ST model in case they need backup mode after looking at logs, for treatment emergent centrals.  So, at least for now, no VAuto and no EasyBreath.

How do the DME's and insurance work? (I did not go through insurance for my unit)... will they swap units at some point if he can't tolerate the non-easy breath waveform?  I am hopeful it will be OK.  The sleep center uses the ST model and during the sleep study he said it was very comfortable...

I wonder if the S/VAuto hardware is exactly the same as the ST hardware, but they have just disabled the EasyBreath for some reason... or if it is different hardware/blower and can't physically do EasyBreath... or there is something about timed mode that makes Easy Breath impossible??

Also, I have been trying to get oxygen approved... his cardiologist suggested supplemental O2 might help his heart failure.  That has been a nightmare also.  They claim he needs an overnight home O2 study after 2 weeks of therapy to see if he qualifies... and the two sleep study O2 records and another one he had in hospital can't be used for some reason... the one in hospital is > 30 day old (because the sleep Dr has been jacking around for 6 weeks now with delays).  Sleep Dr put it on script but insurance will not allow since "not qualified" for O2.  Can someone tell me what hoops I have to jump through to get this approved?  If a Dr. wants it added, how can it be proven to insurance?  And how do we do a valid nighttime test once he is on Bilevel?  His O2 should be better on bilevel... and may not qualify with percentages... but if cardiologist still wants him on it, how do we prove that to insurance?

[Sleeprider]

The ST is not appropriate for treating "treatment emergent centrals". That is not listed as one of the therapeutic functions intended for this machine. Your doctor has some pretty common misconceptions of ST therapy. In order to treat centrals, pressure support would have to be set too high for you to tolerate on every breath, and it would actually make he problem worse. This is the function of the adaptive servo ventilator, which provides pressure support when needed, as needed to resolve CA.

If you don't mind, how much are you on the hook for the ST? We can point you to a number of ways to get the same machine, or the one you want, sometimes for much less. If you don't have a written agreement on machine exchange up front, it doesn't exist.

Most positive air pressure units by Resmed use the same internal components, but the main boards have the logic programming and are not interchangeable. If you want the features of a different machine, you have to buy that machine.

On supplemental oxygen, these multiple tests are not required for approval. It requires enough evidence of a medical necessity, which can be the previous study and the doctors prescription based on medical necessity. While CPAP/BPAP may improve SpO2, there is no requirement to withhold supplemental oxygen therapy contingent on evaluating the efficacy of PAP. They are two separate claims and issues and are not interdependent for approval. Get the script from the cardiologist, submit the claim and if it is denied, then appeal. At worst, a portable recording oximeter can be used at home to verify the necessity of supplemental oxygen.

You are under no obligation to continue using these suppliers or doctor if they are not responsive to your needs at the lowest possible cost. If you have any kind of insurance at all, you should be using an in-network provider and submitting claims. If you choose to buy out-of-pocket, the expenses should apply to deductibles. If you are indeed buying out of pocket, then approval of any device or therapy is not contingent upon insurnace approal, but only requires a prescription to be filled by a supplier. You need a new supplier.

[jtech1]

They wont put him on ASV because of his low ejection fraction. It is all medicare... so not sure what the cost yet. The titration study showed very low centrals... may be more related to the heart failure than treatment... but when the titration study has him at one pressure for one sleeping minute and one central occurs, it blows up to AHI of 60... which statistically could not be more wrong! Until he gets a few full nights at the recommended treatment level of 16/7 with BR OFF we will not have any accurate numbers. I am just hoping that the equip can be changed if necessary. The DME should be able to tell me, right?

[Gideon]

Sleeprider, I want to see charts but if centrals increased dramatically as stated in the above post, can you think of any reason not to try EERS since ASV is ruled out by ejection factor?

edit (Quote removed)

[SarcasticDave94]

Call me curious, what was the LVEF % in question? 45% or higher number "permits" ASV as is currently. Mine was 55% BTW, tested to allow ASV via echocardiogram.

In my opinion, it sounds like what probably will happen is the device the doctor is determined to force on you is a square peg for round holes scenario that will eventually be proven to not work. It's vital to note how bad therapy is on the wrong machine if/when that occurs. Noting bad therapy results include the AHI and other numbers but also feel, discomfort, "it's hard to breathe out" or similar as well. Then you'll get the "Doc it's not working. The numbers are bad. It's to hard to breathe with this. We need this instead. Edit/redo the script." or something like that. The game they're playing only delays the correct treatment; we're talking delays of several months.

As for one machine (say the ST as example) provided by a DME and insurance payments does not work and they are convinced another is medically necessary (say ST-A or better ASV) is sought after next, it requires a script change and as best I know will require exchanging units with that DME.

PS if oxygen supplement is needed to add to any xPAP, there should be a standard or heated hose with oxygen bib available.

Edit add: as bonjour posted EERS may be a consideration

[Gideon]

They wont put him on ASV because of his low ejection fraction.  It is all medicare... so not sure what the cost yet.  The titration study showed very low centrals... may be more related to the heart failure than treatment... but when the titration study has him at one pressure for one sleeping minute and one central occurs, it blows up to AHI of 60... which statistically could not be more wrong!  Until he gets a few full nights at the recommended treatment level of 16/7 with BR OFF we will not have any accurate numbers.  I am just hoping that the equip can be changed if necessary.  The DME should be able to tell me, right?

Without question, the equipment can be exchanged.  Medicare will require justification.  Your cost will depend on if you have a supplemental plan or not.  You have until 7 December to get one for the next year if you choose.  If you bought it on your own your choices may be more limited.

What frequently happens with Treatment-Emergent Central Apnea is the machine has significantly improved the users breathing, to the point where the 'air' exchange is improved which is where the problem comes in.  This improved, more efficient, breathing is washing out too much CO2 from his blood.  This is bad because a primary drive for breathing is having a 'high' level that chemoreceptors detect and say breathe now to get this CO2 out of the system.  That signal is not being sent because the CO2 is not there because the machine did its job of improving the breathing.  Unfortunately, this delays the next breath causing a Central Apnea.  Why the signal to breathe is too much CO2 instead of too little O2 I don't know.

Thus my note to Sleep Rider about EERS which is a mask modification designed to increase the amount of CO2 re-breathed thus increasing the amount in the blood and preventing the Central.

[Sleeprider]

Sleeprider, I want to see charts but if centrals increased dramatically as stated in the above post, can you think of any reason not to try EERS since ASV is ruled out by ejection factor?

edit (Quote removed)

Fred, we have seen EERS can mitigate nearly 100% of treatment emergent centrals in some individuals and result in a 20 to 40% improvement in tidal volume and minute vent.  These are anecdotal results with a very limited number of members but I have been floored by what I have seen so far. EERS could potentially be combined with supplemental oxygen as well, and would still function as expected.  Calculations for using supplemental oxygen with CPAP are in the Oxygen Bleed wiki.   While this treatment is not yet recognized by mainstream medical community, I think it has a lot of potential. 

I think it would be interesting to contact Dr. Robert J Thomas who wrote the development work for EERS and ask if he has also observed this improvement in respiratory function https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3998090/ This is actually an OSCAR related call because no other software can so concisely offer the data that shows this improvement.

[Gideon]

Jtech, can you post some charts please.  

Enhanced Expiratory Rebreathing Space (EERS) is new and not widely used.  We have recent examples on this forum that this therapy eliminates Treatment-Emergent Central Apneas.  It looks like you are managing a good candidate for this treatment.  It is basically a mask modification that moves the mask vent a bit further away from the mask.  This allows the rebreathing of a small amount of CO2 and the elimination of the Treatment-Emergent Central Apneas.  
Does this sound like something you are comfortable doing? 

http://www.apneaboard.com/wiki/index.php...ace_(EERS)

[jtech1]

I was not aware of EERS, but you can bet I will read up on that now.  I think the best course of action will be to get a few days OSCAR charts on the ST device and then determine whether changes will be needed.  The EF is 20%.  So, I do not want to make any changes without Dr input, but I want to be smart enough to know what to recommend or point out to Dr, and be on top of any issues in case (most likely) they do not look at any data sent in until next appointment.

I have attached the first CPAP/BiPAP titration levels and the follow-up BiPAP only titration... the original CPAP titration seemed to be done properly... spending about 5 minutes at each level.  It seemed to resolve OAs but created CAs.  They switch to BiPAP with pressure support of 4 and tried a bunch of different levels, but still had CAs.  The second night they started at PS of 4 (I assume to reconfirm results form the first night's BiPAP), and then ramped things up from there.  I wish they would have spent more time at some of the lower levels since 30 seconds or 1 minute do not provide accurate numbers.  Thoughts?